Coding and billing are essential aspects of keeping your ophthalmology practice viable—and understanding the complexities of ophthalmic billing and coding is crucial for precisely and confidently navigating this intricate and evolving landscape.
With reports highlighting that inefficient documentation and inaccurately billed charges cost healthcare providers an estimated $75,000 of revenue annually, cutting down on—or entirely preventing—these mistakes is vital.1
But how often do these faults occur in practice? “Based on my experience with chart audits, I have found that most practices have an error rate of approximately 20%,” says Brittney Irwin, a consultant in BSM Consulting’s Billing, Coding, and Compliance Division. “These mistakes can occur in various areas, including office visits, modifiers, diagnostic tests, and surgical procedures.”
So, what are the common ophthalmology coding and billing pitfalls that practitioners unknowingly fall into? What impact can a lack of compliance have? How can eyecare professionals safeguard against making such mistakes?
4 common ophthalmic coding/billing mistakes
What are the most common areas of uncertainty surrounding ophthalmology coding and billing?
1. Not identifying the payer’s policies.
As Matthew M Baugh, COT, MHA, OCS, OCSR, Manager of the American Academy of Ophthalmology’s (AAO's) Coding and Reimbursement Division tells us, when it comes to coding, the number one rule is to identify the payer and the relevant coverage policies.
Failing to do so could mean missing potential documentation requirements or other rules that payers have. “All payers do not follow the same rules. Commercial carriers may offer plans with open or closed networks. Practice contracts specify which plans you participate in. Rules vary based on participation.”
2. Not correctly choosing between E/M and eye visit codes.
Mr. Baugh says that for US ophthalmologists—especially those early in their careers—choosing the right office billing code is a frequent source of confusion.2 “One of the most frequent questions that we receive—and one of the most common sources of error—is determining whether to bill evaluation and management (E/M) codes (992xx) or eye visit codes (920xx) for a visit,” he says.
In addition, the AAO’s Coding Experts are often asked how to code and bill for intravitreal injections and premium lens services and how to use modifiers appropriately.3 Practitioners can avoid coding and billing mistakes by considering the documentation in a patient’s chart and determining the level of service met for both the E/M and eye visit codes when choosing.
If the payer accepts either an E/M code or eye visit code and the documentation requirements are met for both, ophthalmologists may choose the code with the higher reimbursement.
3. Missing required elements.
In addition to an interpretation and report, all separately reimbursable ophthalmic testing services require a physician order, indicating the specific test(s), site (right, left, or both eyes), and medical necessity for all delegated testing services, but Mr. Baugh explains that this can be another area in which mistakes can happen.
"Many electronic health records (EHRs) help facilitate the documentation of the required interpretation and report, but many fall short in helping to obtain the written order documentation requirements. The Code of Federal Regulations (42CFR Section 410.32) states that diagnostic tests may only be ordered by a treating physician. Tests that are not ordered by the physician who treats the beneficiary are not reasonable and necessary."
4. Missing or minimal documentation.
Similar errors occur with the comprehensive eye code (920x4), which includes the two most frequently billed exam codes.4 The specific documentation requirements laid out by Current Procedural Terminology (CPT) include the initiation or continuation of a diagnostic and treatment program, but some practitioners fail to document the treatment component—meaning that they are missing the required documentation for the comprehensive eye code.
Missing or insufficient documentation is a major source of coding and billing errors. “If physicians’ documentation is not thorough and does not support the chosen level of service, this can be problematic,” Ms. Irwin cautions, again making this imperative for practitioners to ensure.
Insurers, including Humana and Aetna, have policies indicating they will review high-level office visit services (level 4 and 5 E/M codes and the comprehensive eye code) to determine whether the chosen level of service is appropriate.5,6 They then can adjust the office visit code based on their review of the documentation—making it imperative to ensure that the documentation you provide supports the code you have selected.
Prevent ophthalmic coding/billing errors through external auditing
The first step in addressing any issue is identifying it—and determining the potential causes so they can be addressed. “Eyecare professionals can only prevent errors by first identifying the occurring errors,” Ms. Irwin says.
“Consider using an external auditing team to review a variety of chart documentation to ensure it meets the criteria for office visits, diagnostic test orders and interpretations, surgery/procedure codes, and highly scrutinized modifiers like -24 and -25. Alternatively, you can develop an internal auditing process to review and train on errors found within the practice’s documentation.”
Mr. Baugh agrees that strengthening areas of weakness with outside help is crucial. “Knowing the difference between E/M and eye visit codes is important not only for compliance purposes but also to maximize reimbursement appropriately,” he advises. “Ongoing education from a trusted source is critical as coding and billing requirements change.”
Documentation is critical
Attention to detail is key when dealing with complex documentation. “Regardless of the selected code, the documentation must support it,” Ms. Irwin explains. “Physicians or scribes should take a few minutes at the end of each encounter to review their documentation and ensure it meets all requirements for the specific code.
For example, if the patient is within the global surgery period and you want to bill for an office visit with modifier -24, does your documentation support the claim that an unrelated problem was addressed during the post-operative period?”
Conclusion: Clean coding and billing
The continual decline of reimbursements for physicians means it’s more important than ever to ensure that mistakes are prevented, that all documentation supports the level of service billed for, and that everyone involved in ophthalmology coding and billing is sufficiently trained and up to date on the latest changes in requirements.
With all this in place, eyecare professionals can continue to provide much-needed services to patients—and ensure that they are appropriately paid for their important work.
