By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement
CMS commissioned a national audit of intravitreal injections. It asked Noridian, which is its national Supplemental Medical Review Contractor (SMRC), to review a sample of claims from 2019. The error rate was 29%.1 The most common problems were as follows.
Problem—no response to the documentation request. When audits occur, does your practice have protocols in place to make sure that you don’t miss the deadline for submitting the requested documentation? When it comes to avoiding audit failure, this is the low-hanging fruit.
Solution—train staff and physicians on your protocol. First, make sure that your practice has a detailed protocol to promptly comply with an audit request (see last month’s Savvy Coder). Next, find an effective way to frequently remind staff and physicians about this policy.
Problem—insufficient documentation. The SMRC emphasized that incomplete information was a common problem.
Examples. AAOE members have shared the following examples from their experience with SMRC audits:
- Missing documentation of medication dosage
- Documenting dosage in mg or mL only, not mg and mL
- Missing or incorrect diagnosis per payer policy
- Lack of a procedure note
- Not documenting wastage of 1 unit or greater
- When wastage was less than 1 unit, not indicating that residual medication less than 1 unit was discarded
EHR problems. Make sure that EHRs include all the required documentation. Some standard templates don’t include all the necessary fields; others have been found to hard-code inaccurate or incomplete dosages for medications.
Solution—perform an internal review for each medication type used. Download the Academy’s Intravitreal Injection Documentation Checklist at aao.org/retinapm. Also familiarize yourself with any relevant LCD and/or LCA that your MAC has published (aao.org/lcds).
As part of your practice’s internal chart audits, include a scheduled review of intravitreal injection documentation. Include each medication type that your practice uses, as the requirements vary. (Consider running your internal chart audits on a quarterly schedule, looking at a different targeted service each quarter.)
Problem—billing the wrong number of units. If you inject Eylea (aflibercept), 2 mg/.05 mL, that would be considered 2 units, based on the descriptor for its HCPCS code (J0178 injection, aflibercept, 1 mg). Mistakenly billing that as 1 unit not only would cause an audit failure but also would be a very costly mistake.
What about Visudyne (verteporfin)? According to the descriptor for HCPCS code J3396 (injection, verteporfin, 0.1 mg), the billable unit is .1 mg. Although the drug comes in a 15-mg single-use vial, usually not all of that is used, as the dosage is based on the patient’s weight. So if you report that you used 150 units, you may initially get the correct reimbursement, but you should expect a future Recovery Auditor Contractor (RAC) chart review as the wastage was not reported with modifier –JW.
Solution—carefully report units used (and, if applicable, units wasted). Reporting the appropriate units for the medication is essential for correct coding and appropriate reimbursement.
When using Visudyne for photodynamic therapy (CPT code 67221), you should document the medication used and wasted, and report both amounts on the claim form. For more guidance, visit aao.org/retinapm, where you can access various documentation checklists and the Coding for Injectable Drugs web page, which includes guidance on reporting wastage.
Problem—missing or misused modifiers. The SMRC found many claims that didn’t include a required modifier. In other instances, the documentation didn’t support the modifier that had been appended to the CPT code.
Solution—know your modifiers. Make sure you include the appropriate laterality modifier (–RT, –LT, or –50). These are required to identify the site of service and track frequency of treatment per eye. Make sure you are correctly using other surgical modifiers, including –58, –78, and –79. (For help with modifiers –58 and –79, see the Modifier Mastery videos at aao.org/practice-management/resources/videos.)
Identify and Address Problems
In your practice, internal audit reports are essential to identify coding errors promptly. When you identify an error that resulted in overpayment, submit a voluntary refund to the payer, followed by a corrected claim. Proactively uncovering and resolving these mistakes will eliminate denials in an audit.
Download this free resource. See The Profitable Retina Practice: Medication Inventory Management, which is free to AAOE members and is available at aao.org/store.
1 https://noridiansmrc.com/completed-projects/01-309/. Accessed Dec. 29, 2022.
Get Help Checking Your Charts
Would your practice’s documentation of cataract surgery and/or intravitreal injections survive an auditor’s scrutiny? Visit aao.org/consulting for services that can help you conduct an internal audit.