Expert: Knowing guidelines will help avoid audit trap

Each subspecialty has its own guidelines that must be followed.

Issue: April 10, 2008

ByRiva Lee Asbell

The fear of being audited by Medicare remains one of the primary concerns of practicing ophthalmologists. Driven by this, many resort to undercoding, or even not coding certain services, diagnostic tests and procedures. This review presents some guidelines and tips to help you avoid the audit trap as seen in various subspecialties.

Retina

Riva Lee Asbell

Improper or lack of chart documentation in two areas usually sets the audit trap in this subspecialty: interpretation and report requirements for diagnostic tests; and the performance and documentation of elements counting for a comprehensive examination with specific reference to extended ophthalmoscopy.

Almost all special ophthalmic diagnostic tests mandate an interpretation and report that addresses clinical diagnosis, comparative data and clinical management. This document needs to be separate from the consultation letter unless it is specifically designated as an interpretation and report within the body of the report.

Tips

If you are including the interpretation and report in your consultation letter, make sure it is labeled as such.
Always address the comparative data and clinical management in the interpretation and report, even if it is duplicative of information in the impression and plan.
Without a proper interpretation and report, you cannot bill for the professional component, and monies will be recouped by Medicare under audit.
Many retinal specialists perform the examination up to dilation and then do extended ophthalmoscopy. Then the extended ophthalmoscopy is counted as two elements of the examination — optic disc and posterior segment as well as extended ophthalmoscopy. Under audit, you will be allowed one or the other. If extended ophthalmoscopy is coded, then the E/M service will be no higher than E/M level 3 even if all the other examination requirements are met.
You cannot count extended ophthalmoscopy as the two examination elements and also bill the extended ophthalmoscopy. No double dipping.
You must do a separate interpretation and report for extended ophthalmoscopy if you are going to bill for it. All requirements in CPT must be met.
My preference is for the interpretation and report to be a separate document, although, technically, if it is included in the consultation letter, that should suffice.

Cornea

As a colleague of mine was fond of saying, “Medicare is not medical.” And coding definitions are not necessarily medical definitions. Prime examples are the CPT definitions of penetrating and lamellar keratoplasties. An article in CPT Assistant defined penetrating keratoplasty as replacement of full-thickness tissue, whereas lamellar keratoplasty is, by coding definition, replacement of partial-thickness corneal tissue.

A coding dilemma accompanied the emergence of cornea procedures such as DLEK and DSAEK. The common denominator in these procedures is that layers of corneal tissue are replaced, thereby warranting the procedures to be considered as lamellar keratoplasty. Surgeons objected, citing that the eye is “penetrated” and the procedures thus meet the definition of penetrating keratoplasty. Under audit, you may have a problem.

Tips

If your carrier has deemed that you need to use 66999 for these cornea layer replacement surgeries, then you must use it. If not, use CPT code 65710.
If you use an unlisted code, you cannot get reimbursed in the ASC. You cannot bill the patient because the procedure is covered for physician payment.
There was a code proposal before the CPT Editorial Panel in February. If it passes, then codes will be issued for 2009.

Cataract

Clinical circumstances that enable a case to be considered and coded as complex were defined in 2001.

The CPT definition is:

“66982 Extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.”

The CPT changes have been further elucidated:

“66982 has been added to delineate procedural differences associated with the removal of extracapsular cataract(s) and lens insertion performed in the pediatric age group, on patients who present with diseased states, prior intraocular surgery, or with dense, hard and/or white cataracts. The presence of trauma, or weak or abnormal lens support structures caused by numerous conditions (eg, uveitis) and disease states (eg, glaucoma, pseudoexfoliation syndrome, Marfan’s syndrome) require additional surgical involvement, and utilization of additional techniques and surgical devices. A small pupil found in a patient with glaucoma or a past surgical history may not dilate fully, and will require iris retractors through additional incisions. Capsular support rings to allow the placement of an intraocular lens may be required in the presence of weak or absent support structures.

“Pediatric anatomy contributes to the complexity of cataract surgery. The anterior capsule tears with great difficulty and the cortex is difficult to remove from the eye because of intrinsic adhesion of the lens material. Additionally, a primary posterior capsulotomy or capsulorrhexis is necessary, which further complicates the insertion of the intraocular lens.”

Recent audits on cataract surgery have focused on medical necessity for diagnostic tests in order to ascertain that unnecessary testing did not occur.

Tips

A complication encountered during a case, such as vitreous loss, does not render the case as complex.
Insertion of endocapsular rings renders the case as complex.
Be sure to use supporting diagnoses such as ICD-9 code 364.81 (floppy iris syndrome).
Make sure all tests have an order in the chart and bilateral services are not billed if there is surgery being performed in only one eye.
Support the medical necessity of the surgery by using an Activities of Daily Living (ADL) form filled out by the patient.

Oculoplastics

There were recently two audits in which oculoplastic surgeons were specifically targeted for all services and subsequently found at fault for the outpatient office visit/consultation coding as well as the surgical coding. The auditor was not well trained and made numerous errors. Nevertheless, monies were refunded. A series of scenarios and tips to put you on your guard follows.

Tips for office visits/consultations

Do not bill for either a level 4 E/M encounter or comprehensive eye code unless you have performed a dilated fundus examination. There are some contractors/carriers who do not require dilation for comprehensive eye codes.

Tips for surgery

Do not use the set of codes for orbitotomy with bone removal unless you have actually removed bone. Attaching tissue through drill holes does not qualify for this.
Superficial musculoaponeurotic system procedures are not to be coded using 15776. This code is reserved for head and neck surgery consisting of massive myocutaneous flaps after extensive surgery.
It is imperative that the surgeon has a mastery of all graft codes in CPT other than those found in the ophthalmology section. Graft codes are found in the integumentary and musculoskeletal sections. Do not code free composite grafts (ie, tarsoconjunctival) as skin grafts.
Blepharoplasty pitfalls include insufficient documentation of ADL and patient problems leading to audit findings of lack of medical necessity; failure to consider lower eyelid blepharoplasty as cosmetic; and lack of sufficient photographic documentation.

Glaucoma

Glaucoma is another subspecialty that faces audit challenges for diagnostic testing interpretation and report requirement fulfillment. This is readily apparent with OCT and visual fields.

Tips

You must have a separate interpretation and report that describes the clinical management and comparative data. The printout automatically generated is not sufficient.
It is better, almost essential, to have a separate document for interpretation and report rather than a scribble on the back of the visual field or within the body of the examination, where it will frequently be missed by an auditor.
If you are performing visual fields on only one eye, then you must append modifier -52 because the reimbursement for bilateral codes such as this is based on both sides being tested.
Be careful when billing for extended ophthalmoscopy for glaucoma. A thumbnail-sized sketch does not fulfill the detailed drawing requirement. Make sure to check your contractor/carrier’s Local Coverage Determination for specific requirements.

For more information:

Riva Lee Asbell can be reached at www.rivaleeasbell.com.

CPT codes, copyright 2008, American Medical Association.