Co$tly Coding Errors AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES

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1 Co$tly Coding Errors

2 Financial Disclosure Sue Vicchrilli, COT, OCS AAO Director, Coding & Reimbursement has no financial interests or relationships relative to this live activity to disclose.

3 Error #1 Applying the same rules, or perceived rules to all payers. The #1 rule in coding is who is the payer?

4 Premium IOLs I submitted a claim with a -GY modifier to Aetna for our premium lens charge per the patient request. They applied it to the patients deductible at a lower rate. Now the patient is asking why she has to pay our agreed fees when Aetna states she owes a lesser amount. Can someone advise me how to handle this situation with our patient? She already signed and paid for the agreed amount of what our office charges for this non covered procedure.

5 Premium IOLs Not all payers follow CMS rules regarding premium IOLs. Some payers have their own payment/coverage policy, which if you're par with them, you'll need to follow their unique rules. You can't sidetrack them either by not billing what may be a covered benefit. HCPCS modifiers such as -GY are not recognized by all payers. Follow the remittance advice.

6 Bilateral Surgical Procedures For Medicare Part B: Single line item appended with modifier -5 A 1 in the unit field Payment is 15% of the allowable Medically Unlikely Edit (MUE) effective date: April 213

7 Bilateral Surgical Procedures For commercial plans: Same as Part B, or Single line item, modifier -5 and a 2 in the unit field, or Two line item appended with -RT/-LT, or Two line item with -RT and -5-LT

8 Bilateral Testing Services Ophthalmology is one of the few specialties that still has a few tests payable per the right/left side of the body: Fluorescein angiography ICG Extended and subsequent ophthalmoscopy A and B scans

9 Bilateral Testing Services Only when there is pathology in both eyes, it is appropriate to bill for both eyes.

10 Bilateral Testing Services Depending on the payer: Single line item appended with modifier -5 and a 2 in the unit field, or Two line item with modifiers -RT and -LT Payment is 1% of the allowable for each eye. Exception is Medicare Part B where 2% of the -TC of the second test is reduced

11 Error #2 Documentation for exams

12 Documentation for Exams E/M vs. Eye codes must know allowables for each payer Dilation alone doesn t mean it s comprehensive. Copy paste/forward hurts you. Cloned documentation Particularly ROS

13 Documentation for Exams Auditors asking for consecutive dates of service, not single encounters. Physician signature

14 Comparative Billing Reports Received by 1, ophthalmologists Outliers E/M Eye visit codes Ophthalmologists are more likely to be audited on exam than tests/surgeries

15 Error #3 Audits It s not a matter of if, but when. How prepared are you when the request for records arrives? All payers conduct audits.

16 LCDs Local Coverage Determinations Medicare Part B Updated as necessary Notified by participation on listserv on weekly basis Only 3% of practices participate in listserv

17 Local Coverage Determinations Kansas/Missouri WPS Blepharoplasty: Blepharoptosis/Brow Lift Botulinum Toxin A & B Category III Codes Drugs/Biologicals Low Vision Services Removal of Benign lesions Scanning Computerized Ophthalmic Diagnostic Imaging Visual Fields

18 Local Coverage Determinations Arkansas/Oklahoma Novitas Benign Skin Lesions Blepharoplasty Cataract/complex cataract Comanagement E/M in Nursing Facility Glaucoma Treatment/Aqueous Drainage Device Lacrimal punctal plugs Punctal plugs SCODI

19 Local Coverage Determinations All others Under Resources

20 OIG Report September 215 Questionable Billing for Medicare Ophthalmology Services

21 OIG Report September 215 Why the study? Since 21 over 1 ophthalmologists investigated for potential fraud

22 OIG Report September 215 Why the study? 6.7 billion paid to 44,96 providers for ophthalmology services that screen for, diagnoses, evaluate or treat two prominent eye conditions: Wet AMD (2.2 billion), Cataracts (3.5 billion)

23 Wet AMD Lucentis: Injections more often than 28 days per eye, Beyond maximum annual dosing recommendation per eye, Laser surgeries with concurrent injections

24 Wet AMD Palmetto GBA post payment documentation request Beneficiary name and date of service on all documentation Beneficiary weight used to calculate dose given Name and amount of drug administered Signed physician/provider order for the drug Stage of treatment for accurate dose administration Calculation for the drug (i.e. first dose or subsequent dosing) Documentation of administration of the medication Documentation legible and complete (including signature(s)) Abbreviation key (if applicable) Relevant history and prior treatment, if needed, to support medical necessity of administration and amount of drug used in administration, which may include documentation (i.e. peer-reviewed medical literature) supporting any off-label use as applicable Initial patient history and physical or initial consultation related to the treatment

25 Wet AMD High number of: Fluorescein angiography ICG Fundus photography Extended/subsequent ophthalmoscopies OCT not mentioned

26 Complex Cataract Comparative Billing Report Unusually high billing with Additional diagnosis can support claim

27 Error #4 Failure to verify bundling edits CCI and commercial payers

28 CCI Edits Injections bundled with all surgeries Extended and subsequent ophthalmoscopy bundled with all minor and major retinal surgeries Retina/Glaucoma OCTs bundled with fundus photography Fundus photos bundled with ICG Gonioscopy bundled with ALT, SLT, MLT

29 CCI Edits Visual fields bundled with blepharoplasties (many payers no longer require VF) Fitting of bandage lens bundled with all corneal minor/major surgical procedures

30 CCI Edits link to CMS webpage. Updated quarterly Applies to same patient, same encounter, same eye. Not to global period!

31 Modifier misuse Error #5

32 Modifier -24 Appended to unrelated to surgery exam performed within the global period Different diagnosis from surgical case is not enough Typically interim exam between cataract cases is not billable

33 Modifier -25 Appended to E/M or Eye visit code when it is significantly separately identifiable from the minor ( or 1-days) surgical procedure While medically necessary, if the established patient exam is performed solely to confirm the need for the minor procedure performed on the same day, the exam is not billable.

34 Modifier -59 Appended to test and surgeries (not exams), that are separately identifiable. Primary function is to break CCI bundling edits. Volume is so high for CMS that HCPCS modifiers to better describe the situation.

35 In lieu of -59 for CMS only -XE -XS Separate Encounter, A service that is distinct because it occurred during a separate encounter Separate Structure, A service that is distinct because it was performed on a separate organ/structure -XP -XU Separate Practitioner, A service that is distinct because it was performed by a different practitioner Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service

36 Questions?

37 PQRS Value-Based Modifier

38 215: Penalties PQRS -2 percent in 217 Value-Based Modifier *based on 215 PQRS reporting and cost of care -2 percent in 217 (groups of <1 and solos) -4 percent in 217 (groups of >1 or more) EHR Incentive Program -3 percent in 217 ASCQRS -2 percent in 217

39 PQRS 215 Medicare Part B Medicare as a secondary payer Railroad Medicare Medicare Advantage Plans depending upon your contract with them.

40 PQRS 215 EHR and MU simultaneously Cataracts Measures Group August 1 last day to register with IRIS Registry 9 individual measures via claims or IRIS Registry October 31 st last day to register with IRIS Group reporting

41 PQRS 215

42 PQRS 214 The checks have been distributed The letter is in the mail if subject to a payment reduction Reports available now The appeals process if you feel penalized in error

43 PQRS Guidelines published Nov Federal Register Webinar Dec 8 EyeNet article

44 Questions?

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