Are You Making These Ophthalmic Coding Mistakes?

Ambulatory surgery centers have some of the cleanest claims with the fewest errors of all healthcare providers. Still, there may be a way to put a little extra polish on your business practices by looking for common billing problems. In this brief article, I will discuss six common mistakes that we find when reviewing claims for ophthalmic procedures and show you how to correct them.

Mistake #1: Not charging a separate facility fee for each procedure.
Medicare policy allows a facility fee for each eligible procedure, so in cases involving bilateral or multiple procedures, your claim should identify each facility fee with an appropriate modifier-either 50 (bilateral procedures) or 51 (multiple procedures).

For example, if a surgeon performed a bilateral levator resection for upper lid ptosis (CPT code 67904), list the code on the claim as follows: 67904 -50

You should make a separate charge for each procedure. Medicare will base reimbursement on 100 percent of the allowed amount for the first procedure and 50 percent for the second, less applicable deductibles and coinsurance. In this case, that would be 150 percent of the allowed amount for 67904.

The same goes for multiple procedures. If a surgeon performs cataract surgery (CPT code 66984) and trabeculectomy (CPT code 66170) in the same session, list the procedures as follows: 66170
66984 -51
Medicare will base payment on 100 percent of the largest procedure and 50 percent each for up to four secondary procedures.

Some third party payers may argue that they owe you only one facility fee. But don't let payers get away with that. Know what your contracts stipulate, and be prepared to fight to claim all the reimbursement you are owed.

Mistake #2: Assuming all the cost of all prosthetic devices is part of the facility fee.
If you've been lumping all supplies and devices into one facility fee, you may be missing part of your reimbursement. You are no doubt already billing for corneal tissue (V2785), but did you know that you can also bill separately for aqueous shunt (L8612), hydroxyapatite ocular implant (L8610), and other ophthalmic prostheses? Many prosthetics enjoy separate reimbursement.

Intraocular lenses are a notable exception to this rule. The HCPCS codes for these products are V2630, V2631, and V2632, but Medicare bundles IOLs with the facility fee for cataract surgery (66984). However, many third party payers for commercial plans may reimburse for IOLs separately.

Mistake #3: Accepting procedures that are not reimbursable.
Consider this scenario: A patient comes to your facility for a lower lid ectropion repair (CPT code 67917) and, in the same sitting, the surgeon does an upper lid blepharoplasty (CPT code 15822). At this time, Medicare covers the latter procedure for the surgeon, but not for the ASC. The ASC can not bill the patient privately. Only when the procedure is a non-covered procedure for both the ASC and the physician (such as a cosmetic lower lid blepharoplasty) can the patient be held responsible for the facility and the professional fees.

To avoid having surgeons perform procedures for which you can't bill, it's vital to communicate with them before every procedure, determine how they have counseled the patient and what they plan to do. Consider carefully whether to schedule the case or ask the surgeon to make other arrangements.

Mistake #4: Balance billing the patient for "bundled" procedures.
Medicare publishes a comprehensive list of "bundled" codes that are not usually reimbursed along with the primary procedure. For example, canthoplasty (CPT code 67950) is considered to be a part of, or bundled with, extensive repair of ectropion (CPT code 67917). Only the ectropion repair is eligible for reimbursement. Balance billing the patient for the canthoplasty is a violation of your Medicare participation agreement.

Medicare updates the list of bundled procedures every quarter in the National Correct Coding Initiative policy manual; currently there are more than 118,000 pairs of codes that cannot be used in the same claim. You can purchase a hard copy or electronic copy of all the coding edits by calling the National Technical Information Service (HCFA's authorized distributor of CCI codes) at (800) 553-6847. To stay current, you'll need to purchase a new manual every quarter, but don't throw away older versions for at least five years. Medicare may decide to audit you for previous years' claims, and you may have to refer to previous versions to prove that you coded correctly.

Mistake #5: Incomplete documentation of pre-op care.
It may seem basic, but it's critical to make sure that every medical record contains the following:
- indications for surgery;
- medical clearance for surgery;
- informed consent for surgery.

Even though your facility may not be involved in doing pre-op histories and physicals and obtaining informed consents, if these elements are missing from the record, your claim will be invalid. We handled one case where an employee of a surgeon fabricated these documents. The falsified records ended up in the ASC, casting suspicion on its claims for reimbursement.

Mistake #6: Inaccurate accounting for anesthesia time.
Medicare regulations for anesthesia reimbursement underwent significant changes at the beginning of 2000. The new regulations permit reimbursement for discontinuous care, meaning that the anesthetist is allowed to go from one patient to another and then back to the first patient and be reimbursed for the discontinuous time units. Often, however, the anesthetist will not document his start and stop times, so it may look as though he was treating two patients at the same time.

It's essential to account carefully for time expenditures. Overlapping time periods, also known as concurrencies, are evidence of misrepresentation on the claim and may lead to criminal or civil sanctions.

If you think you've made any one of these six mistakes, now is the time to correct them. Spot checking your charts and the corresponding claims is a fairly easy way to ensure your continued success.