Audit-Proof Your Practice: Coding & Billing Hot Spots

Is regular internal auditing part of your eye care practice’s compliance plan? It should be. And if you’re wondering what topics to audit, it helps to think like a government auditor so that you can reduce your risk of denials or even being caught up in a RAC audit.

RACs are independent contractors that review Medicare claims and collect contingency fees based on the amount they recover from overpayments. They look at reports from the HHS Office of Inspector General for hints about where coding and billing might be going awry so that they can collect their percentage of the haul.

The good thing about the OIG is that they tell everyone exactly what they’re looking for, says Arnold & Porter Kaye Scholer’s Alan Reider, JD, MPH, who spoke at last year’s Millennial Eye Live Conference in Nashville. The watchdog agency publishes work plans and reports that help you understand which coding and billing practices are under scrutiny so that you can correct any similar problems at your eye care practice.

Reider suggest that coders and billers look at OIG documents such as 2015’s “Questionable Billing for Medicare Ophthalmology Services.” It’s a couple of years old but still quite relevant. This report describes how the OIG investigated coding and billing patterns for 1,726 ophthalmology providers who had billed a total of $768 million during the time period under scrutiny. In the sample they examined, “$171 million was for services associated with the measures on which these providers demonstrated questionable billing,” the report says. The most prevalent coding and billing problems the OIG auditors found were for:

Procedures to treat wet AMD

Lucentis injections more often than 28 days per eye, Lucentis injections beyond the maximum annual dosing recommendations per eye, and laser surgeries with concurrent biologic injections or drug administration. The HCPCS code for 0.1 mg ranibizumab injections is J2778.

Tests to diagnose wet AMD

More than three annual fundus photography exams (92250), more than five annual ophthalmoscopy exams (92225, 92226), more than five annual fluorescein angiographies (92230, 92235) or indocyanine green angiographies (92240).

You might also look at coding and billing patterns for 92242 (Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral), which CPT® added for 2017.

“Ophthalmology is seeing a ton of outside audits, and where we tend to be failing is the reporting of diagnostic tests in general,” says Rhonda Buckholtz, CPC, CPC-I, CPMA, CRC CDEO, CHPSE, COPC, CENTC, COBGC, CGSC, CPEDC, who spoke at a recent auditing webinar sponsored by Eye Care Leaders. Documentation is absolutely crucial for diagnostic tests. “Simply pulling the results from the EMR is not enough to satisfy documentation requirements for interpretation and report,” Buckholtz says. If you do it that way, “no where in the record do you see who interpreted the report, and no where do you have documentation that you discussed the results with patients,” she explains.

Complex cataract surgeries

Providers in the sample billed for 66982, 66983 or 66984 when codes for less complex cataract procedures would have been more appropriate, the report says. RACs have since set their sights on claims for complex cataract surgeries that practices may have incorrectly coded or that are poorly documented.

In 2017, two RACs—Performant Recovery and Cotiviti—announced they’d be reviewing documentation for complex cataract surgery claims “to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.” They’re looking at claims coded as 66982, 66983, and 66984, which requires documentation that the cataract procedure wasn’t routine.

Medical Necessity

To determine how your Medicare carrier defines medical necessity for 66982 and other complex cataract codes, you need to check your Local Coverage Determination (LCD). For example, Part B MAC CGS Administrators says it allows 66982 for conditions that necessitate the following:

  • “Insertion of iris retractors through additional incisions
  • Mechanical expansion of the pupil using hooks
  • Creation of a sector iridectomy with subsequent suture repair of iris sphincter
  • Use of a Malyugian ring and multiple iris sphincterotomies created with scissors.
  • The need to support the lens implant with permanent intraocular sutures
  • Placement of a capsular support ring necessary to allow secure placement of an intraocular lens
  • Performance of pediatric cataract surgery with intraocular lens insertion
  • Use of intraocular dyes (e.g. trypan blue or indocyanine green) to stain the lens capsule in the setting of a mature cataract.”


The OIG report describes billing problems associated with the following modifiers:

22— (Increased procedural service)

24— (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)

25—(Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the day of a procedure or other service)

For example, an ophthalmology practice might use modifier 25 is when a doctor performs an E/M service in addition 65205 (Removal of foreign body, external eye; conjunctival superficial). CCI bundles FBR removals in with E/M services, but modifier 25 unbundles them. To report modifier 25 in this kind of encounter, the note must document why the physician found it necessary to do an E/M service (history, exam, medical decision making) in addition to the FBR.

Reminder: Doing an internal audit in your ophthalmology practice or hiring an external auditor to review your claims is an important part of your compliance plan. When you do an audit, it’s crucial that you define the scope before the audit. After, educate providers about what you find during the audit to correct future problems, Buckholtz stresses.

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