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    Cataract Comanagement Compliance—CMS Outreach Prompts Internal Reviews

    By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Are you a cataract surgeon whose patients are sometimes comanaged? If so, are your coding and documentation compliant with your payers’ rules?

    CMS outreach to outliers. Last year, CMS—working with RELI Group, a contractor—identified cataract surgeons who referred a high proportion of patients to other clinicians for post-op care. RELI Group sent these ophthalmologists a comparative billing report in October. (Similar reports were sent to clinicians who billed a high proportion of complex cataract procedures and to those who performed a lot of Nd:YAG procedures within six months of cataract surgery. For more information, see “CMS Releases Comparative Billing Reports on Cataract Surgery.”)

    Comparative billing reports are educational tools. The comparative billing report is neither an audit request nor a warning of an impending audit. These reports were developed as part of a CMS educational program. The aim is to prompt practices to conduct internal chart audits to confirm that their documentation and coding are compliant. Here are some key areas to focus on.

    Comanagement Is Not Routine

    According to the Academy-endorsed Comprehensive Guidelines for Comanagement of Ophthalmic Postoperative Care, a routine arrangement with a referring provider for comanagement services is not appropriate. Each case is unique, and the comanagement decision should be transparent to the patient; agreed upon mutually by patient, surgeon and co-manager; and clinically appropriate for the patient.

    Document Informed Consent and Transfer of Care

    When the patient requests and consents to comanagement, an informed consent should be documented in writing. The comanaging provider should also agree to accept the patient care. Documentation should state when the surgeon transfers care to the comanaging provider, and also should list all relevant clinical information provided. The Ophthalmic Mutual Insurance Company provides comanagement risk assessment recommendations , as well as examples of consent forms.

    Coding for Comanagement of Cataract Surgery

    Two modifiers represent the complementary roles of surgical comanagement:

    • Modifier –54, surgical care only
    • Modifier –55, postoperative care only

    Use of these two modifiers indicates that the surgeon relinquished part or all of the post-op care and the comanaging provider accepted transfer of that post-op care.

    Straightforward example. Suppose a surgeon provides standard cataract surgery (CPT code 66984) and provides zero days of post-op care. The claim would be submitted as 66984–54 with –RT or –LT appended to indicate the right or left eye, respectively. The comanaging provider would report 66984–55 with –RT or –LT appended and would also report the date range of the postoperative care in item 19—or the Electronic Data Interchange (EDI) format’s equivalent—of form CMS-1500.

    How to code for shared post-op care. What if, for example, the transfer of care happens seven days into the 90-day global period for a complex cataract surgery (CPT code 66982) in the left eye?

    The surgeon would bill for providing both the surgical care and seven of 90 post-op days, and would code for that as follows:

    • 66982–54–LT
    • 66982–55–LT, with the date range for the seven days of post-op care included in item 19

    The comanaging provider would bill for the balance of the post-op care as follows:

    • 66982–55–LT, with the date range for the 83 days of post-op care included in item 19  

    Avoid common problems with shared post-op care. When the surgeon transfers some, but not all, of the post-op care to another clinician, it is easy to make mistakes with the documentation and billing. Keep the following tips in mind:

    • The transfer letter should include the date of transfer of care so that both doctors bill appropriately.
    • The chart documentation of the post-op days provided should match the claim submission details.
    • If there is a complication and the patient care is returned to the surgeon, the claim should be corrected to accurately reflect the number of postoperative days provided by the surgeon.
    • Bill for the appropriate number of post-op days. If you bill for fewer and allow the referring provider to be reimbursed for a greater number of post-op days than is warranted, that could be interpreted as a kick-back and a potential target of the Office of Inspector General (OIG) or Department of Justice (DOJ).

    Comanagement Coding Tips

    When coding for comanaged patients, keep the following pointers in mind:

    Who is the payer? Not all insurance payers recognize comanagement modifiers and arrangements, so you should check your payer’s unique policy. Check Medicare payer policies and guidelines by reviewing your payer’s local coverage determinations.

    No comanagement billing within a group practice. For example, an optometrist and surgeon in the same group practice do not report comanagement care with modifiers –54 and –55.

    If multiple surgeries are performed, all or nothing. For example, when a combined minimally invasive glaucoma surgery and cataract surgery is performed, comanagement can’t be split with the surgeon continuing the post-op care for the glaucoma procedure while transferring post-op care for the cataract surgery.

    Anti-Kickback Statute Risks

    A recent $2.9 million settlement over comanagement kickback allegations highlights the risk associated with paying comanaging providers, directly or indirectly, as opposed to all remuneration flowing through Medicare. In particular, the settlement announcement stated: “The fees paid to referring optometrists for patients who received premium lenses or laser-assisted cataract surgery were in addition to the reimbursement already received by the optometrists from Medicare and Medicaid for performing postoperative cataract care and were not tied to or commensurate with actual postoperative services specifically attributed to premium IOLs or laser-assisted cataract surgery rendered, and thus constituted unlawful remuneration under the Anti-Kickback Statute.”

    For more information, see “Ophthalmology Practice Agrees to Pay Over $2.9 Million to Settle Kickback Allegation.”