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Certain services may trigger Medicare audits
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Medicare auditors were very active in 1998, and it appears they will continue to be active in 1999. The federal government has allocated $200 million to the Justice Department for Medicare audits in 1998 and 1999. Why do I predict that the audits will continue?
Early experience with audits in 1998 showed a return of approximately $17 for every $1 invested in the audits. Thus, if the audits use the whole $200 million and they continue to return repayments at the rate of 17:1, the government stands to collect a whopping $3.4 billion. Yes, I believe the audits will continue through 1999.
The instructions given to the auditors require that only fraud and abuse will be prosecuted. While honest mistakes will not be prosecuted, providers will be required to pay back to Medicare any improper payments.
Doctors often ask whether certain behavior or certain claims’ contents are more likely to result in a Medicare audit. My experience with offices around the country indicates that Medicare and other payers watch for certain “triggers” or “red flags” while processing claims. Two of the most common are frequent charges for extended ophthalmoscopy and eye exams, and services in nursing homes.
Ophthalmoscopy part of routine visit
Ophthalmoscopy is considered to be part of the office visit whenever the doctor deems it appropriate. There is no code in Current Procedural Terminology (CPT) for ophthalmoscopy. Extended ophthalmoscopy has its own codes (92225 or, subsequently, 92226), but it is meant to be reported only when the patient has special needs and only if the medical record clearly indicates that something more than ophthalmoscopy was done.
As with all procedures having CPT codes, it is very important to use this code, 92225, only when the service you have provided matches the definition in CPT. To quote the CPT definition: “Routine ophthalmoscopy is part of general and special ophthalmological services whenever indicated. It is a non-itemized service and is not reported separately. 92225 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma) with interpretation and report; initial.”
Many payers, including many Medicare carriers, use this definition as a starting point and add additional requirements. For example, many payers will reimburse for extended ophthalmoscopy only if the patient’s diagnosis is found on a list of diagnoses linked with this service. The procedure might be approved when a patient has a retinal hole and not approved when the patient has a corneal ulcer.
Other payers require that the doctor must have performed at least two procedures for examining the peripheral retina to have the service qualify as extended ophthalmoscopy. For example, the doctor might choose to do binocular indirect ophthalmoscopy and slit-lamp examination with Volk lenses, or an examination that would include Volk lenses and Hruby lens.
Some payers require the drawing to be done with colored pencils, even though CPT does not require it. Medicare requires that the drawing be large enough to permit the progress of the disease to be easily followed from one examination to the next.
Do not “unbundle” services
Doctors must understand that extended ophthalmoscopy is meant to be a special ophthalmological service not used on a routine basis. Doctors must also understand that frequent use of special ophthalmological service codes will always invite additional scrutiny by the payers. Payers believe it suggests that the provider might be “unbundling” the service, representing its individual parts rather than its whole. Payers will always prefer — and thus scrutinize less — providers’ use of codes that “bundle” several services together in a single code, such as comprehensive ophthalmological services.
The first doctor to review an eye record being audited is often an ophthalmologist, so it is important to understand how he or she may view this service. Many general ophthalmologists believe extended ophthalmoscopy is within the domain of the retinal subspecialist and feel that general ophthalmologists and optometrists would never use the code.
What should you do? Do not report and claim extended ophthalmoscopy unless the service you have provided matches the definition in CPT and fulfills the specific requirements of the payer involved. In other words, follow the rules.
Extended ophthalmoscopy is a special ophthalmological service and, as such, is meant to be billed in combination with the appropriate office visit code. Which office visit code should you use? Choose the code based upon the content of the medical record for each visit, focusing upon the case history, the physical examination and the medical decision making. Extended ophthalmoscopy can be billed in combination with evaluation and management codes (99000 series) or general ophthalmological services (92000 series).
Nursing home care frequent audit target
More and more eye doctors are becoming involved with providing eye care for nursing home residents. Auditors believe the special circumstances present in this environment provide opportunities for overuse of the Medicare system.
If you are providing care in this environment, it behooves you to become an expert on all the rules associated with the system (CPT, ICD-9 and Medicare carriers’ rules) and to adhere to them scrupulously. If you provide nursing home eye care, you will be audited eventually, so the care you provide must be carefully chosen and the records of that care must be carefully kept.
Nursing home residents have special eye care needs, and caring for nursing home patients can be professionally rewarding. Your professional judgment is critical in this environment, because the residents are often limited in their ability to participate in their care.
Threshold visual fields may be indicated for a particular patient, but you must decide if you should go through the motions of the procedure and bill Medicare if the patient is unable to respond to your instructions or to the test itself.
For Your Information:
- Charles B. Brownlow, OD, FAAO, is executive vice president of the Wisconsin Optometric Association and vice president of operations of Practice Management Inc. Dr. Brownlow is a member of the AOA Eye Care Benefits Center executive committee and the ECBC subcommittee on coding issues. He may be contacted at Practice Management Inc., 5721 Odana Rd., Ste. 102, Madison, WI 53719; (800) 827-1945; (608) 274-5044; fax: (800) 308 -7189; (608) 274-2674; e-mail: brownlowod@aol.com.