• Savvy Coder

    Best Coding Tips of 2016—Testing Services and Cataract Surgery

    By Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement

    Download PDF

    Each year, Academy and AAOE members share thousands of coding-related comments at Codequest Coding Courses, via listservs, and by email.

    In 2016, many practices have run into trouble during audits. You can learn from their costly mistakes.

    Fear No Audit

    The problem. Postpayment au­dits frequently find a discrepancy between what was documented and what was billed. As a result, practic­es have had to return large sums of money to payers.

    The solution. To help you improve your documentation, the Academy has launched 3 online courses:

    • Eye Visit Code Documentation Guidelines (Product #0120406V)
    • Testing Services Documentation Requirements (#0120407V)
    • Complete Guide to Document­ing and Coding Cataract Surgery (#0120408V)

    For more information, and to place your order, visit aao.org/store.

    Delegating Tests to Staff

    Some tests must be performed by physicians, others can be delegated. For Medicare Part B, tests that can be delegated have both a technical com­ponent (–TC) and a professional (–26) component.

    Delegated tests have 3 levels of supervision1 under Medicare:

    General supervision means that the procedure is furnished under the physi­cian’s overall direction and control, but the physician’s presence is not required during the performance of the proce­dure. Under general supervision, the physician has an ongoing responsibility for the training of the nonphysician personnel who actually perform the diagnostic procedure and for the main­tenance of the necessary equipment and supplies.

    Direct supervision in the office setting means that the physician must be present in the office suite and is immediately available to furnish as­sistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the proce­dure is performed.

    Personal supervision means a physi­cian must be in attendance in the room during the performance of the service.

    Avoid this mistake. Recent audits have demonstrated that the ordering or supervising physician wasn’t always on-site when tests with direct supervision were performed. As a result, Medicare has been able to recoup significant amounts of money.

    Note: While Medicare Part B recog­nizes 3 levels of supervision, commer­cial plans recognize only direct supervi­sion for all delegated testing services.

    SCODI and Fundus Photos

    The latest audit trigger involves CPT codes 92250 Fundus photography and 92134 Scanning computerized oph­thalmic diagnostic imaging [SCODI], posterior segment, with interpretation and report, unilateral or bilateral; retina. SCODI is often performed the same day as an intravitreal injection, and physicians may order fundus photog­raphy on the same day, too. As codes 92250 and 92134 are bundled, practices may choose to submit the photogra­phy code for payment because it has a higher allowable.

    The high use of the fundus photog­raphy code has triggered audits, with practices under scrutiny for:

    • Use of modifier –25, which is used to unbundle codes
    • Injection documentation
    • Frequency of injected drug
    • Supervision of testing
    • Medical necessity of fundus photog­raphy

    To learn your Medicare Adminis­trative Contractor’s documentation requirements for testing services, look for the relevant local coverage deter­mination at aao.org/practice-manage ment/coding/updates-resources/practice-management/coding/updates-resources.

    Cataract Surgery

    A number of cataract surgeons have had to return payments for cataract surgery after audits revealed documentation problems, including the following:

    • No evidence of the patient’s pre­operative best-corrected visual acuity (BCVA) in the record.
    • No evidence of the patient having reported impairment of visual function resulting in restriction of activities of daily living.
    • No signed operative note/report.
    • No documentation indicating that the patient desires surgical correc­tion; that the patient has received an explanation of the risks, benefits, and alternatives; and that the expected out­come will significantly improve visual and functional status.

    Further Reading. Read “Best Coding Tips of 2015: Part 1” (November 2015) and “Part 2” (December 2015), as well as “#1 Lesson From the Chart-Auditing Service: Get Your History Right” (June 2015).


    1 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/B0128.pdf. Accessed Sept. 21, 2016.