and billing in optometric practices has become a hot topic within the last couple
of years. As someone who gives upwards of 150 lectures per year, I get to hear quite
a few stories on how coding and billing is done in practices all across the country.
Some of these methods are quite creative! I also get to hear a litany of complaints
questioning the rejection or denial of a claim and the ensuing loss of profitability.
Enjoyable as it may be to recount these wonderful moments of creativity,
it's become clear that understanding the most common coding errors could be of value
to the optometric population at large. So, I will tackle the top 10 coding errors
and handle a few myths at the same time. Please keep in mind that I am using The
Centers For Medicare and Medicaid Services (CMS) as the benchmark. Even though Medicare
often sets the standard, there will be certain carriers that have variances to my
list. So here we go, a la David Letterman ...
The Top 10
Description: Claims submitted are exact duplicates of previous
claims submitted. Claims are often denied as duplicates for the following reasons:
►The claim was previously processed (i.e., no payment made, allowed amount applied
to deductible on the initial claim). The provider re-files the claim to "correct"
it. The second claim submitted is considered a duplicate, as the initial claim was
►The provider automatically re-files the claim to seek payment if the initial claim
has not been paid within 30 days.
WHAT TO DO:
1. If the reason for non-payment is in question, call Provider
Services to verify the claim's processing information. Do not re-file a claim until
you know a new claim is necessary.
2. Check the claim status before re-filing a new claim; the claim
could be pending in the Medicare system for payment or for additional information
necessary to complete processing. Again, call Provider Services to check claim status
2. Non-covered services
Description: Billing for services not covered under the Medicare
WHAT TO DO:
Keep in mind
that there's a lengthy list of Medicare exclusions such as: Personal comfort items;
self-administered drugs and biologicals (i.e., pills and other medications not administered
by injection); cosmetic surgery (unless done to repair an accidental injury or improvement
of a malformed body member); eye exams for the purpose of prescribing, fitting or
changing eyeglasses or contact lenses in the absence of disease or injury to the
eye; routine immunizations; routine physicals; lab tests and X-rays performed for
screening purposes; hearing aids; routine dental (care, treatment, filling, removal
or replacement of teeth); custodial care, services furnished or paid by government
institutions; services resulting from acts of war; and charges to Medicare for services
furnished by a physician to immediate relatives or members of the same household.
Stay up-to-date on current exclusion policies by checking with
your Medicare carrier and/or their Web site for changes. Most carriers will post
changes to policies and their effective date. If not, go directly to Medicare's
Web site at www.cms.hhs.gov and find them there.
3. Lack of medical necessity established
Description: The payer deems the services billed not medically
WHAT TO DO:
will be denied because the payer does not deem the procedure for this diagnosis
to be a "medical necessity." Check the Medicare newsletters for the list of covered
diagnoses for a particular service.
Check the Local Coverage Determination (LCD) on the respective
carriers' Web site for a listing of covered diagnoses for a particular service and
the appropriateness of conducting the tests. You must establish the medical necessity
of common tests such as photos (both anterior segment and posterior segment) in
the medical record before ordering the specific procedure. Medical records should
reflect how the testing allowed you to provide a higher level of care to the patient.
The testing performed should be necessary to your medical decision making, resulting
in a better outcome for the patient.
4. Inappropriate bundling of services
Description: This indicates a lack of awareness of the National
Correct Coding Initiative Edits (NCCI) that govern appropriateness of tests being
performed together on the same date of service. Alternately, it may indicate a lack
of understanding of the appropriate code status of a specific CPT code. For example,
payment for "B" status code services is always bundled into payment for other services,
whereas with "C" status codes, the local carrier determines bundling and the appropriateness
of the procedure and subsequent reimbursement.
WHAT TO DO: Access the
NCCI Edits on the Medicare Web site (http://www.cms.hhs.gov/NationalCorrectCodInitEd/)
to review which codes can and cannot be billed together on the same date of service,
as well as the appropriate modifiers to use in those situations. Also, familiarize
yourself with the status code of the CPT procedure code you work with.
These change at minimum on a quarterly basis. You can also find
this information in commercially available programs such as ReimbursementPlus (www.ReimbursementPlus.com).
5. Beneficiary eligibility
Description: You submit a claim for processing and the beneficiary/patient
does not have Medicare eligibility. Claims are often denied for eligibility
for the following reason:
►The beneficiary Medicare number is invalid on the claim.
►The beneficiary is not eligible to receive Medicare benefits.
►The beneficiary's claims must be filed to another insurance plan.
WHAT TO DO:
patients. Verify the Medicare number on the patient's Medicare card and file the
claim exactly as it is printed on the card. Verify the patient's effective date
for Medicare Part B from their Medicare card. Medicare cannot pay for services prior
to the patient's effective date and will not pay for services if the patient has
terminated his Medicare benefits.
Beneficiaries who enroll in a Medicare "replacement" HMO must
be submitted to that insurance plan instead of Medicare Part B. To obtain Medicare
eligibility, call your carrier's Provider Service department.
6. Incorrect carrier
Description: The claim was submitted to the incorrect payer/contractor
WHAT TO DO: It's important
to screen patients and be aware of the types of services provided prior to submitting
a claim to the carrier. Check the patient's Medicare card and verify the Health
Insurance Claim (HIC) number on the card. Patients with traditional Medicare coverage
will have HICs of nine digits followed by an alphanumeric suffix.
Patients who have railroad retirement (a type of federal health
care coverage) will have HICs with an alpha prefix followed by either six or nine
digits. Verify whether a Medicare-replacement Health Maintenance Organization (HMO)
covers the patient. You can obtain this information by calling the Provider Service
department, or online via your carrier's Web site.
Additionally, pay special attention to whether you have provided
refractive services and are submitting a refractive claim with a refractive diagnosis
to the refractive carrier, or whether you have provided medical eye care services
and are submitting a medical claim to the medical carrier. If you are not a contracted
provider for a carrier, always collect from the patient in full for all services
and materials you provide. Help the patient get reimbursed for your services by
offering to fill out and submit the claim on his or her behalf, but don't accept
financial liability for a claim that a carrier has no legal obligation to pay.
7. Medicare is the secondary payer
Description: The care of a Medicare patient may be covered
by another payer through coordination of benefits. Medicare may be the secondary
payer in our offices for the following reasons:
►Working aged. The Medicare patient is: 65 years or older, employed full- or part-time
by an employer who has 20 or more full- or part-time employees, and covered under
the Employer's Group Health Plan (EGHP); or covered under the EGHP of an actively
employed, full- or part-time spouse whose employer has 20 or more employees.
►Liability and auto/no-fault liability: Section 953 of the Omnibus Budget Reconciliation
Act of 1980 was amended by the Deficit Reduction Act of 1994. It precludes Medicare
payment for items or services to the extent that payment has been made or can reasonably
►Where the primary claim should be filed under auto, medical, Personal Injury Protection
(PIP), no-fault, worker's compensation, or any liability insurance plan or policy
including self-insurance plans.
►Workers' compensation: Medicare will be the secondary payer for work-related illnesses
or injuries covered under a workers' compensation plan.
►Veteran's Affairs (VA): VA records are set-up by information received by the Social
Security Administration. Veterans who are entitled to Medicare may choose which
program will be responsible for payment of services covered by both programs.
WHAT TO DO:
information concerning the working/retirement status of each Medicare patient with
each visit. Be sure to stay updated. Contact your Service Provider department about
potential conflicts and the appropriate coordination of benefits.
8. Improper diagnosis
Description: Services were denied because the diagnosis listed
as primary was not a covered diagnosis for the procedures performed.
WHAT TO DO: Check your
specific carrier's local coverage determination (LCD) policy for the specified procedure
to obtain a list of covered diagnoses, generally found on their Web site, or accessible
on Medicare's Web site. Also familiarize yourself with the appropriate policies
for medical necessity and documentation requirements. Be cautious of automated programs/software
that provide a covered diagnosis for any given procedure.
Keep in mind that having a covered diagnosis does not mean you
can automatically perform any procedure for which the covered diagnosis exists.
You must prove and document the reason in the medical record to justify doing the
procedure. For example, let's look at doing routine anterior segment photography
because your patient presents with allergic conjunctivitis. Despite having a "covered
diagnosis" for taking the photo, there most likely is insufficient medical necessity
to take an annual photo of the allergic eye.
9. The claim is missing a modifier or has
an incomplete or invalid modifier
Description: The modifier necessary to process the claim correctly
is either missing, incomplete, or invalid for the specific procedure and diagnosis
indicated on the claim form.
WHAT TO DO:
Know the proper
use of the CPT modifiers that exist and are appropriate to use for the specific
condition or situation. The CPT modifiers are listed in their entirety in Appendix
A of the current version of the CPT Manual. You can obtain the CPT manual from the
American Optometric Association or from the American Medical Association. You should
also know that misuse and abuse of modifiers are under the scrutiny of the Office
of Inspector General (OIG) and that can result in significant penalties.
10. Provider number is missing or incomplete
Description: Items #24K and #33 are filled out incorrectly,
with the UPIN (unique provider identification number) or information is missing,
thus causing a denial of the claim.
WHAT TO DO: For item 24K,
enter the personal identification number (PIN) or national provider identifier (NPI)
of the performing provider of service/supplier if you are a member of a group practice.
When several different providers of service or suppliers within a group are billing
on the same form CMS-1500, show the individual PIN or NPI in the corresponding line
For item #33, enter the provider of service/supplier's billing
name, address, ZIP code, and telephone number. These are required fields. Enter
the PIN (or NPI when implemented), for the performing provider of service/supplier
who is a member of a group practice. Suppliers billing the DMERC should use the
National Supplier Clearinghouse (NSC) number in this item. Enter the group UPIN,
including the two-digit location identifier, for the performing practitioner/supplier
who is a member of a group practice.
Of notable mention ...
Now I'll clear up some of the myths and misunderstandings I referred
Many believe that Medicare can only look at Medicare records.
CMS has the ability to look at an array of records within a given practice. Simply
speaking, Medicare has the ability to look at any subset of your patient records,
whether they are private pay, covered by other insurance carriers, etc. ... if it
believes that there's the potential for fraudulent behavior or practices. HIPAA
guidelines do not protect you or your patient records from CMS if the potential
for fraudulent activities or abuse exists.
I also see a lot of overuse and abuse of modifiers -25, -59, and
-52. Recent studies by the OIG have found significant problems with the use of modifiers
-25 and -59. Modifier -59 is used to indicate that a provider performed a distinct
procedure or service on the same day as another procedure or service.
The OIG study found that a significant amount of claims (40%)
did not meet the appropriate requirements or guidelines. The OIG currently recommends
post-payment reviews of those claims.
Modifier -25 is used to allow additional payment for evaluation
and management services performed by a provider on the same day as a procedure.
The E/M services must be significant, separately identifiable, and above and beyond
the usual preoperative and postoperative care associated with the procedure. The
OIG study found that approximately 35% of claims were outside of program requirements.
Modifier -52 is used to report reduced services provided during
a physician-patient encounter. Many use -52 on an E/M code (920XX codes are also
considered E/M codes) to reduce the price for cash-paying or non-insured patients
to indicate that they've given reduced administrative services. This is an improper
use of the -52 modifier. As an example, it should be used when performing a visual
field unilaterally, as the visual field is defined as a bilateral test, thus the
reduced services of performing it on just one eye.
Just stay up-to-date
Coding for physician services and materials is seemingly complex,
but keeping current with published policies and guidelines that are easily obtainable
should help ensure a high degree of success within your practice. Avoid these "Top
Ten" coding and billing errors and find yourself on the fast track to fewer coding
headaches and much greater profitability.
available on request.
Rumpakis is the president and CEO of Practice Resource Management Inc.,
a medical consulting firm. He is the author of
ReimbursementPlus.com, a Web-based
CPT Reimbursement & Fee-Setting application. He's also a member of the AOA and
the American Academy of Professional Coders.