On January 11, 2002, a New Jersey optometrist was sentenced to seven years in state prison, and was fined more than $1 million dollars for three counts of defrauding 29 insurance carriers.
Specifically, he was found guilty of providing routine glasses and eye exams to several patients at little or no cost, and making up the difference by billing their insurance companies for extended ophthalmoscopy, serial tonometry and gonioscopy. He was also found guilty of instructing his staff to create false patient records and charts, and for changing and falsifying records and charts himself to prepare for possible audits of the claims he had submitted.
While this optometrist knowingly and willingly committed fraud, other optometrists can find themselves in trouble because of misunderstandings or lack of knowledge. The following 11 points illustrate common coding mistakes optometrists make.
1. Not knowing your third-party codes as a result of HIPAA.
HIPPA has a set of codes that every in-surance company must use. The deadline for compliance with these code sets was October 16, 2003. However, some insurance companies have either asked for extensions or are in the process of becoming compliant, which can make the billing process very confusing. Thats why optometrist Douglas C. Morrow of Auburn, Ind., says, Until everyone is HIPAA compliant, if there is a question about the code set being used, the doctors staff should call the insurance companys customer service department.
Kristi Stull, Dr. Morrows employee in charge of billing, also suggests that optom-etrists and their employees stay on top of the insurance company lit-erature. Doing these things has added a little bit more to my workload, but in the long run, I have seen that the payments are coming in a little more quickly.
2. Billing the wrong insurance company.
Coding expert and optometrist Randolph Brooks of Ledgewood, N.J., says optometrists can find themselves in trouble when they bill medical insurance com-panies for vision exams and vision insurance companies for medical exams. Vision coverage is for comprehensive eye examsnot related to diseaseand medical insurance is designated for medical exams, and often times is a dif-
ferent insurance company, he says. Because of this complexity, you must ascertain the type(s) of cov-erage the patient has up front, so your staff does not bill the wrong company. Also, Dr. Brooks says the patient must know prior to the exam what out-of-pocket charges he or she will be expected to pay, if any, so that the optometrist is not charged.
Optometrist Mike Todd of Augusta, Kan., who is the chairman for the American Optometric Associations subcommittee for coding, adds, Patients may try to get you to file their medical exams under vision because medical insurance usually involves a deductible, and they dont want to have to pay that, he says. Or, they may ask you to file a medical exam for a vision exam because they have already used their vision benefits. Dr. Todd warns that pleasing the patient could get you in trouble because you have to legitimately be able to say the visit was a vision examination or that there was a definite diagnosis for a medical ex-amination.
3. Billing both insurance companies for the same procedure.
Dr. Brooks says that some optometrists may wrongly bill both the patients medical and vision in-surance for the same procedure. It is possible, however, to bill [the pa-tients] medical service to their medical insurance and their vision service to their vision insurance, if he or she is being seen for both a medical and a vision service on the same day, he says. And, in fact, patients in that case can actually have two copays.
4. Billing an office visit and foreign-body removal, done on the same day, to the patients medical insurance.
Optometrist Charles B. Brownlow, who works for a medical record consulting firm in Waupaca, Wis., says the only way you could bill an office visit to the patients medical coverage on the same day as a foreign-body removal, is if the two were un-related. For instance, lets say a patient came in for a glaucoma evaluation, but during that evaluation, the doctor found lashes scratching on the cornea and decided to remove them, he says. Epilation is a surgical procedure, so the procedure would be separate from the office visit. Dr. Brownlow says the doctor would inform the payer of this by putting a -59 modifier (separate procedure) on the surgical procedure and by using the glaucoma diagnosis code with the office visit and the trichiasis code for the epilation.
5. Using time at the wrong time.
Dr. Brooks says another possible coding mistake is when optometrists use time to increase a visit to higher coding levels when no time has been spent counseling or coordinating the patients care.
The three important factors in selection of a 99000 Evaluation and Management (E&M) code are history, exam and medical decision making. Time is only to be con-sidered when counseling and coordination of care dominate the vis- it, he explains. You cant simply look at the number of minutes spent with the patient and use that to determine what code level youve performed.
6. Using maximum reimbursement to choose a code.
Dr. Brooks says you cannot choose a code based on reimbursement. The bottom line is you have to work from the correct side of the coding equation, he says, which is based on history, exam and the medical decision making.
7. Coding incorrectly for extended ophthalmoscopy.
Dr. Brownlow says there must be a medical reason for this pro-cedure, and you must perform all the components for the procedure to be considered a true extended ophthalmoscopy.
An extended ophthalmoscopy requires the doctor to do a very thorough examination of the inside of the eye through a dilated pupil, he says. And, he or she must provide an interpretation and report in the medical record. In addition to that, Dr. Brownlow says the doctor must make a drawing of what is observed in the eye during the procedure and that some payers require the use of two instruments, such as the binoc-ular indirect ophthalmoscope (BIO) in addition to using the biomicroscope with condensing lenses or perhaps an Hruby lens to look at the back of the eye. Regular ophthalmoscopy, even with the BIO, done simply to examine discs and the retina to see if theres anything wrong, is included in the office visit and is not reported separately, he says.
8. Billing binocular pro-cedures as two units.
While there are certain codes, such as scanning laser ophthalmoscopy (CPT code 92135), that are billed monocularly, Dr. Brooks says there have been cases of optometrists who consistently bill other binocular procedures as right and left eye, instead of the correct way, which is one unit.
The insurance company often discovers months or years later that the doctor was billing incorrectly and asks for their money back, he says.
9. Overusing the level 5 E&M code.
While optometrists are not excluded from using the level 5 codes, Dr. Todd says they may fall under suspicion for using the codes excessively. Internal medicine physicians who are in a hospital setting and see really sick patients who have complicated diagnoses might use these codes fairly often, he says. But, in the normal optometric practice setting, youre not going to be seeing those types of patients that often, so these codes should not be used that often.
10. Not providing the address for Medicares Jurisdictional Pricing.
Dr. Todd says that, more re-cently, optometrists have had to contend with refusal of coverage as a result of not writing the name, street address and zip code of where the service was performed in box 32 of the Centers for Medicare & Medicaid Services (CMS) claim form 1500. He says that it is his understanding that even if the doctor fills in the same name and practice everywhere else on the claim, that Medicare will not process the claim.
Indeed, according to Medicare, effective April 1, 2004, failure to report this information will prevent the claim from being processed, and the O.D. will not be afforded appeal rights.
11. Not providing Medicare with the necessary information for comanagement of cataract surgery.
Dr. Todd and his billing administrator, Gloria Buthe, say optometrists can run into problems with this claim by:
Not providing three items in box 19. You have to provide the date the procedure was performed (discharge date); the date you took over care (accepted care date); and the number of days you care for the patient post-operatively, or you will get a denial, Dr. Todd says.
Forgetting to coordinate coding with the surgeons office. The surgeon must file the claim for surgery with the -54 modifier, indicating the O.D. will provide the postoperative care, Dr. Todd says. The number of days post-op filed by the surgeon plus the number of days filed by the optometrist should add up to 90.
The date of surgery must be the date of service. Even though you see this patient for the first time after the date of the surgery, you must use the date of the surgery for your date of service. This needs to be done in box 24A, Ms. Buthe explains.
Forgetting to accompany procedure code 66984 (cataract surgery) with modifier -55. Modifier -55 states you are comanaging the postoperative care, Ms. Buthe says. If you do not use modifier -55, you will get a denial saying that the money from the surgery has either already been paid to the surgeon or that the claim is a duplicate.
Forgetting to use modifier -79 when comanaging cataract surgery on the patients other eye within 90 days of the cataract surgery done on the first eye. If you comanage cataract surgery on the patients other eye within the 90 days of postoperative care from the surgery done on the previous eye, Ms. Buthe ex-plains, you must use the -79 modifier, which indicates that the surgery is unrelated to the other eye, along with modifier -55 and all of the other information. Not doing this, will get you a duplicate of claim rejection. Ms. Buthe also suggests you indicate which eye was operated on to avoid a duplicate of claim notice. I always indicate RT [right] or LT [left] modifier in the procedure box, in case the patient will require cataract surgery done on their other eye within the 90-day post-operative care, she says.
The New Jersey optometrist mentioned above is serving time because he wanted higher reimbursements from his patients insurance companies. But, perhaps if he had learned from the mistakes of others, he wouldnt have disgraced the profession or himself.
