Unfortunately, too much of the billing and coding education in healthcare focuses on gaming the system to get the most out of insurers. This has led significant fraud waste and abuse in healthcare. In fact, the Department of Justice estimates it may be as much as $100 billion (yes, Billion not million) in healthcare. While we all frustrated by decreasing reimbursement, and while we want to be able to collect fair compensation for the services that we provide to patients, we must be careful to make sure that our billings avoid fraud, waste, and abuse.

Critical Components of Documentation, Coding, and Billing 

The best way to ensure compliance with payor’s rules is to apply 2 critical concepts to all of your documentation, coding, and billing:

  1. Reason for the Visit
  2. Medical Necessity

Reason for the Visit

Reason for the visit is actually a simple concept. It is the reason why THE PATIENT is seeking care from you TODAY. Not the care YOU want to deliver. Trying to “turn an exam medical” or looking for something to justify a specific code that you want to bill tends to lead to significant amounts of improper billing.

Medical Necessity

Medical necessity is another simple concept. It involves only performing services and testing where the results will actually influence or dictate diagnosis and/or treatment of the patient. Medical necessity means that you should follow a symptom-based approach to eyecare (unless specifically dictated by a payor policy).

Top 10 Audit Issues

The majority of improper billing leads back to not following the 2 critical concepts mentioned above. With that said, let’s take a look at the top 5 issues.

  1. Upcoding of E&M codes – while this is a less of a problem under the new 2021 E&M coding guidelines, it is still the number 1 area of abuse. Even though the 2021 changes have made proper code selection easier, not fully understanding the details are resulting in optometrist billing too many high-level codes, especially Level 5 E&M codes.
  2. Overuse of Ophthalmological codes – Many providers bill too many comprehensive examinations that should be intermediate examinations or in many cases, EM codes. The reason for this is the same as the reason for improper upcoding: failure to follow medical necessity.
  3. Medically unnecessary testing – Just because you have an instrument, doesn’t mean you can bill for its use on every patient in every situation. Remember that medical necessity means that you should follow a symptom-based approach to eyecare and only performing testing where the results will actually influence making a correct diagnosis or assist in preparing a correct treatment plan.
  4. Mis-Use of the 59 Modifier -Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. However, this should be rare and ALMOST never has an application in primary eye care. The most common example of abuse is using it to bill fundus photos and scanning lasers during the same encounter for glaucoma.
    (You may have heard there is an acceptable diagnosis list…there was…that is gone…replaced by a national edit against the two codes)
  5. Mis-Use of the 25 Modifier – Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service. The main reason for abuse is when providers do not understand that the office visit is included in the fee for a surgical procedure. The most common example is billing an examination with a foreign body removal.
  6. Blurred Vision as a Medical Reason for a Visit – Using blurred vision as a medical reason for a visit requires certain examination and documentation requirements be met to be considered medically necessary. If the patient complains of blurred vision but the vision corrects to normal with a change in their glasses, the examination is vision.
  7. Major Medical – Vision Therapy Claims – Payors will sometimes pay these claims, but unless you have in writing that every CPT code you want to submit is considered a covered service under the patient’s plan you could find yourself having to repay large sums.
  8. Photography – Unfortunately, photography is heavily abused. you cannot document the absence of disease (except in a few instances), you cannot document absence of change (no exceptions), and photos cannot substitute for ophthalmoscopy.
  9. Vision Plan Improper Exam Documentation – Vision plan requirements can be surprisingly extensive. You should read and be familiar with the history requirements, examination requirements, and dilation rules for each plan you participate in. While you’re at it, read what the agreement says about compliance issues.
  10. Vision Plan Improper Contact Lens Exam Documentation – Contact lens exam documentation requirements can be just as surprisingly extensive. You should read and be familiar with the history (must include the lenses worn, how they are worn, solutions used), examination (must document the fitting characteristics of lenses), findings (must include K’s and SOR), assessment (must state how the patient is doing with the lenses), and the plan (must state what you are doing going forward, even if that is no change). Not knowing the rules can setup you up for audit failure and chargebacks.

Knowing and following the proper guidelines can prevent a lot undue stress and prevent you from having to return large sums of money to a payor. In the next few articles we will go through all of these topics in more detail.

Peter J. Cass, O.D.
VP Development