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  • Savvy Coder

    Why Your Ophthalmology Colleagues Were in the Auditors’ Crosshairs

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

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    What do auditors zero in on? Visit for a list of target areas, plus resources for each of them. Recently, ophthalmology practices have been audited on the following issues.

    Intravitreal injections. In 2019, Novitas, a Medicare Administrative Contractor (MAC), started targeting practices that use a high volume of aflibercept (Eylea) and/or ranibizumab (Lucentis) and subjecting them to a prepayment Target, Probe, and Educate (TPE) audit on up to 40 records. The Academy sent an alert to all members within Novitas’ jurisdiction; this alerted them to the issue and reminded them to use the Academy’s checklist of docu­mentation requirements. Most physi­cians passed the audits. Of those who didn’t initially pass, documentation problems included no record of visual acuity (VA), nothing to support why a particular drug was used, no mention of how the patient is doing on the drug, and no notation of residual medication wasted. (Novitas is the MAC for the District of Columbia, Arkansas, Colo­rado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, and Texas.)

    Audit Help

    Academy and AAOE member benefit: If you receive a request for records from any payer, you can email for guidance.

    Also, take advantage of an extensive list of resources for every audit target at

    Eye visit codes. The Academy also heard from some practices that had been submitting a high volume of Eye visit codes; upon audit, they were down-coded from comprehensive new and established patient exams (CPT codes 92004 and 92014, respectively) to intermediate new and established patient exams (92002 and 92012). Why? The auditor had erroneously applied the documentation require­ments for the E&M codes. Once the auditors were educated about this, either the audit result was dismissed or only a small percentage of submissions were down-coded. Why were a few still down-coded? In those instances, the practice hadn’t performed and docu­mented all 12 elements of the exam.

    Upper lid blepharoplasty. Blepharo­plasty audits don’t happen as often as they used to, but auditors do still some­times target CPT code 15823 Blepharo­plasty, upper eyelid; with excessive skin weighting down lid. Why is payment denied? In some cases, practices had cloned the chief complaint verbatim from one patient’s record to the next; in others, the auditors said that the chief complaint was more cosmetic than functional in nature.

    Blepharospasm Botox injections. If you are billing for a drug that came in a single-use vial, Medicare requires that you use modifier –JW to report wastage. However, payers that don’t follow Medicare’s rules might not require it. Indeed, some practices have found that use of –JW for non- Medicare patients triggered audits. In several of these cases, the audits revealed that practices were using Botox vials packaged for cosmetic—not functional—treatment.

    Cataract surgery. Why have cataract surgeons failed audits of their docu­mentation? Common reasons include: No documentation of best-corrected VA; cutting and pasting the same activity-of-daily-living complaints into the records of multiple patients; and no notation that the patient desires to proceed with surgery.

    Complex cataract surgery. You may trigger an audit if 10% or more of your cataract surgeries are billed as complex (CPT code 66982). And you will fail that audit if you don’t meet the MAC’s documentation requirements for code 66982, even if the surgeries were in fact complex. To find those documenta­tion guidelines, see your MAC’s local coverage determination(s) for cataract surgery at (Note: 66982 is on the list of prepayment TPE audits.)

    What about the commercial audits? While Medicare Part B MACs consider the use of dye for the mature cataract a qualification of complex cataract surgery, many commercial payers may not. You must not take one payer’s rule and apply it to all payers.

    Extended and subsequent ophthal­moscopy. Claims for extended ophthal­moscopy (CPT code 92225) have been denied because the documentation didn’t note scleral depression or the diopter of lens that was used, or the drawings lacked sufficient labeling or detail. Claims for subsequent ophthal­moscopy (92226) have been denied when no change was noted from the last exam.

    Documentation Checklist for Anti-VEGF Drugs

    • Confirm there are 28 days between injections in the same eye.
    • Record surgical order, which should include the drug name, dosage, and indication (di­agnosis) with physician signature.
    • Assess visual acuity.
    • Make sure you record the chief complaint and elements to the history of the present illness (HPI).
    • For new patients, document why the specific drug was chosen.
    • For established patients, document at each visit why you are keeping the patient on the drug and how the patient is responding to it.
    • Document how much of the drug was injected.
    • Document how much of the drug was wasted. If it was less than one unit, include lan­guage similar to “residual medication discarded.” (Remember, never share a vial between both eyes. Correct billing is one vial per eye.)
    • Ensure that the diagnosis is a covered benefit by the particular payer. If it’s not a cov­ered diagnosis, the patient is responsible for the injection and drug costs.
    • Document that the patient desires surgery.
    • Obtain informed consent if it’s the first injection or if there’s a change in medication or eye.
    • Maintain legible medication administration records.