Will Your Optometry E/M Coding Survive An Audit? Here’s How To Tell

Ever wonder whether your Evaluation and Management billing patterns are “normal”? There are benchmarks available to find out—and to assess risk areas in your practice’s revenue cycle management.

Last year, Part B MAC Palmetto issued Comparative Billing Reports (CBRs) and a webinar to analyze billing patterns among optometry practices. And if you’re not familiar with CBRs yet, you should be. Palmetto launched the analysis “because the OIG has found inappropriate billing and over-utilization of optometry services,” the CBR report said.

“According to an OIG report, physicians increased their billing of the two highest level E/M services by 17 percent from 2001 to 2010 for CPT codes 99214 and 99215,” Palmetto noted.

Palmetto Isn’t My Carrier, So Why Should I Care?

The government uses CBRs to put both all payers and providers on notice about potential overbilling that ripe for audits. You can use the data from CBRs to benchmark how your practice’s billing patterns compare to your peers nationwide.

Here’s What Auditors Reviewed

The Palmetto CBR reviewed claims data from about 6,000 optometrists to evaluate their coding for E/M (99201-99215), ophthalmological services (92002-92014), visual field exams (92081-92083), and scanning diagnostic imaging (92133-92134).

Auditors Found These Top Problems With Optometry Claims

  • Lack of orders for diagnostic testing
  • Missing examining physician’s signature
  • Standing orders
  • Medical necessity
  • Cloned records
  • Over/inappropriate use of modifiers 59 and 25
  • Diagnostic tests without interpretation and report

To Assess Your Risk, Find Your Numbers

“Most practice management systems should be able to generate frequency of usage of different CPT codes,” says Vinod Gidwani, founder of Currence Physician Solutions in Skokie, Ill. “These reports maybe subtitled CPT code productivity by doctor, facility, etc.” Use your practice’s EHR and PM software to pull your frequency of 92014 and average minutes per visit.

Next, Check Your E/M Data Against National Averages

Among claims that Palmetto reviewed for optometrists, the average minutes per visit for new patients was 36.40. For established patients, it was 17.40 minutes, says Palmetto’s Craig DeFelice in the webinar.

Because higher-level CPT codes have higher typical minutes, then a higher average minutes per visit indicates that you are generally billing either higher-level CPT codes than your peers, or you are billing for more services per visit.

Among claims for established ophthalmic exam codes 92012 to 92014, physicians report 92014 74 percent of the time. If your practice has reported 92014 more frequently than this, you are on the higher side, according to Palmetto’s data.

Now, Check Your Documentation

If your practice or one of your physicians is an outlier for billing higher-level E/M codes, then you should ensure the clinical notes document good reasons for being an outlier.

Don’t panic: If your percentage of specific code usage is higher than the average, it doesn’t necessarily mean you’re billing incorrectly, but you should take a look at your documentation to ensure that it meets requirements. “Billing differently from your peers is not any indication of wrongdoing,” DeFelice said during the webinar.

CPT code 99212 may be most appropriate for minimal-level visits such as quick conjunctivitis checkups, says Palmetto GBA’s Cyndi Wellborn, RN, in the webinar. “CPT code 99214 may be used following serious eye diseases as long as the MDM is moderate and medical necessity exists to perform nine of the elements.”

Glaucoma Dx Coding Heads Up

The Palmetto auditors also looked at whether providers submitted diagnosis codes at the highest level of specificity—but in most cases, practices fell short.

“We determined that 60 percent of the claims submitted with a diagnosis of glaucoma requiring a stage were not submitted with the additional code,” says Palmetto GBA’s Cyndi Wellborn, RN during the webinar. “Providers should assign as many codes from category H40 (Glaucoma) as necessary to identify the type of glaucoma, the affected eye, and the stage,” she said.

Your documentation should include the stage of glaucoma—if you don’t know it, document that as well, she added. In that case, you’ll use the seventh character of “4” (Indeterminate stage). For instance, H40.1224 (Low-tension glaucoma, left eye, indeterminate stage).

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