The Top Ten Coding and Billing Errors O.D.s Make

Forget "creative coding" - here's how to get it right.

coding & billing
The Top 10
Coding & Billing Errors
Forget "creative" coding — here's how to get it right.

Coding 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

1. Duplicate claim submitted

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 processed correctly.
►The provider automatically re-files the claim to seek payment if the initial claim has not been paid within 30 days.


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 before re-filing.

2. Non-covered services

Description: Billing for services not covered under the Medicare program.

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 and find them there.

3. Lack of medical necessity established

Description: The payer deems the services billed not medically necessary.

WHAT TO DO: The claim 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 ( 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 (

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: Screen your 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 for payment.

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 be expected.

►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: Obtain routine 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 item.

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 to earlier.

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.

References available on request.

Dr. Rumpakis is the president and CEO of Practice Resource Management Inc., a medical consulting firm. He is the author of, a Web-based CPT Reimbursement & Fee-Setting application. He's also a member of the AOA and the American Academy of Professional Coders.