Article Date: 6/1/2013

Coding Strategies
Coding Strategies

“Ch-Ch-Changes”

Effects of the sequestration and big brother’s magnifying glass

JOHN A. McGREAL, JR., O.D., AND JON WEEDING

In addition to the changes we can expect from healthcare reform, the federal government has recently made two decisions, which affect us now.

1. The sequestration

As of April 1, Medicare reimbursement (including ambulatory surgery reimbursement) has been reduced by 2% due to the federal budget sequestration.

Further, costs for drugs administered by physicians included in those claims have been reduced by 2%. This cut is imposed on the 80% portion of the allowed reimbursement a physician receives directly from Medicare. Further, this sequestration reduction applies to EHR incentive bonus payments.

The bottom line: That check from Medicare is likely not a mistake.

2. OIG’s focus on eye care

This year, the Office of the Inspector General (OIG) is focusing on questionable billing in eye care, as 8.65% of Medicare’s total expenditures in 2011 were codes for ophthalmology and optometry. In 2011, Medicare reimbursed more than $8.2 billion for services provided by eye specialists. The 92014 code was the 11th highest paid code of all codes in all specialties. Code 66984 was the fifth highest paid code.

Questionable Codes
Rank CPT code Service
5 66984 Cataract IOL
11 92014 Comp. Eye Exam, established patient
25 92012 Intermediate Eye Exam, established patient
47 92004 Comp. Eye Exam, new patient
63 92083 Visual Field, Full Threshold
67 66821 YAG Capsulotomy
72 00142 Anesthesia For Proc on Eye; Lens Surgery
78 92250 Fundus Photography
87 92235 Fluoroscein Angiography
93 92134 Scanning Laser (SCO DI): Retina
135 67228 Retinal Surgery
141 92134 Scanning Laser (SCO DI): Optic Nerve
161 92136 Ophthalmic Biometry with IO L Power Calc
164 15823 Blepharoplasty, Upper Eyelid
190 92226 Subsequent Extended Ophthalmoscopy
* Evaluation & Management codes (99XXX) were not included because they are not specific to a specialty.

The OIG says it will begin reviewing Medicare claims data from 2011 to identify questionable billing for ophthalmological service (92XXX) codes. Also, it says it will review the geographic locations of providers exhibiting questionable billing practices. (See “Questionable Codes,” left.)

The bottom line: Big brother’s magnifying glass should not concern you if you meet the documentation requirements set forth in the CPT 2013 Standard Edition (American Medical Association; 1 edition, 2012) and the ICD-9- CM 2013 for Physicians, Volumes 1 and 2 (Saunders, 2012). That said, remain current on Medicare guidelines. CE programs, journals and provider websites offer many opportunities for you to sharpen your coding skills. Further, we recommend you implement a practice compliance plan comprised of staff training and doctor coaching, fraud and abuse training, monthly internal chart reviews and periodic outside third party reviews. Profiling and comparative billing analysis should be mandatory. Attention to compliance lowers audit risks, builds a robust practice and helps everyone sleep better at night. Always remember … “forewarned is forearmed.” OM

DR. MCGREAL PRACTICES AT MISSOURI EYE ASSOCIATES IN ST. LOUIS, MO. E-MAIL HIM AT MCGREALJOHN@GMAIL.COM. MR. WEEDING IS PRESIDENT OF COMPLIANCE SPECIALISTS, INC., A BILLING AND CODING COACHING FIRM. E-MAIL HIM AT JON@CSEYE.BIZ. OR, SEND COMMENTS TO OPTOMETRIC MANAGEMENT@GMAIL.COM.



Optometric Management, Volume: 48 , Issue: June 2013, page(s): 78