Reviews may target Medicare prepayment audits of ophthalmology procedure codes

June 8, 2012

By Rebecca Wartman, O.D.

A Medicare carrier medical review probe may be coming to your area soon.

The medical review department at Palmetto GBA, the A/B MAC for North Carolina, South Carolina, Virginia and West Virginia, recently announced it will perform a service-specific prepay probe review on outpatient ophthalmic claims.

MACs in other areas of the nation will probably initiate similar prepay audits program for ophthalmic services in the near future, if they haven’t done so already.

Optometrists and their billing staff must make sure all claims are filed properly by making sure all of the documentation required on claims is provided.

Practitioners should also watch for audit notices in the mail and be prepared to promptly provide any information required by auditors.

Practitioners have only a limited period of time to respond.

Remember these are prepayment reviews so the claim will not be processed until the physician responds to the request to send their records to the carrier.

Here are some steps optometrists can take to help avoid audits and some advice on what to do should an audit notice be received.


While only Palmetto GBA has publicly announced the specific ophthalmic service codes its auditors will be targeting, the list may provide some insight into the services other carriers around the nation will be watching:

1. CPT code 92235 Fluorescein Angiography with interpretation and report
2. CPT code 92004 Comprehensive Ophthalmological services, new patient
3. CPT code 92014 Comprehensive Ophthalmological services, established patient
4. CPT code 92012 Intermediate Ophthalmological services, established patient
5. CPT code 92083 Extended Visual field examination, unilateral or bilateral with interpretation and report
6. CPT code 92250 Fundus photography with interpretation and report
7. CPT code 92002 Intermediate Ophthalmological services, new patient
8. CPT code 92226 Ophthalmoscopy, extended with retinal drawing, subsequent
9. CPT code 92225 Ophthalmoscopy, extended with retinal drawing, initial
10. CPT code 92020 Gonioscopy
11. CPT code 92285 External ocular photography with interpretation and report
12. CPT code 76514 Ophthalmic corneal pachymetry, unilateral or bilateral
13. CPT code 92015 Refraction

All of these services are used within the typical optometric practice.

The proper documentation of these services is the primary concern for auditors. The documentation must be complete, has to clearly demonstrate the medical necessity of the procedure performed, and should fall within the commonly accepted standards of practice.

Practitioners should carefully consider Medicare guidelines when deciding whether to report services with the general ophthalmic codes or the evaluation and management (E&M) codes, and then provide all of the documentation necessary to justify the coding used.

The 10 physical examination elements of an ophthalmologic E&M examination include:

  • Confrontation visual fields
  • Eyelids and adnexa
  • Ocular mobility
  • Pupils/iris
  • Cornea
  • Anterior Chamber
  • Lens
  • Intraocular pressure
  • Retina (vitreous, macula, periphery, and vessels)
  • Optic disc

When using E&M codes, be sure to select the proper level examination.

  • A comprehensive examination consists of eight or more elements and always includes a fundus examination with the pupils dilated.
  • An intermediate examination consists of seven or fewer of the specified elements.

Evaluation and Management (99201-99215) coding should be used when the service requires a minimum of ophthalmic examination techniques.

And refraction (92015) is never considered a part of the ophthalmic service and should not be charged, but it may be billed for denial purposes.

Anytime an additional test or service is indicated, the practitioner needs to write an order for this procedure in the assessment and plan. While the testing can be done on the same day or on another day, the order for the testing must be in place.

If the testing performed is the service being audited and it was performed on a different day from the order, be sure to submit a copy of the examination when the service was originally ordered.

Many of the special ophthalmic services require an interpretation and report to be written. This interpretation and report should be written in a separate section of the chart and not part of the body of the normal examination findings.

Interpretation and report can be written on a separate page in the chart. If the testing is provided on a different day from when the testing was ordered, and if the testing is the only service provided on that particular day, then only the testing should be billed.

Another examination code may be billed if other exam elements are separate from, and not a part of, the testing.

Practitioners need to review their documentation for all services provided for all patients.

One recommendation to ensure your records are properly completed is to review all your documentation at the end of day. Check that all findings, orders, procedures, assessment and plans are complete for each patient in the medical record.

Each patient encounter needs to have a chief complaint and details of the evolution of those complaints along with the medical, ocular, family and social histories properly completed, reviewed and/or updated.

All examination findings need to be clearly documented. Normal findings can be noted as simply “normal,” but any abnormal findings need to be detailed to indicate the specific abnormalities.

All elements for the examinations must be completed to meet the coding standards for the chosen code.

Practitioners can find details on the requirements for billing various ophthalmic services on the provider-specific (optometry/ophthalmology) page of their local carrier website.


Practitioners should be aware that Medicare carriers are also making a point of ensuring the physician signature is legible.

The signature is an important element that practitioners often forget, especially in a one-doctor practice.

Providers of services must be clearly identified in claims along with the date of service and the patient.

Documentation for each and every service should be signed and dated at the end of the service. And any other staff or practitioners adding information to the chart should initial and/or sign the examination as well.

Electronic signatures are permitted for electronic medical records. An office can keep an employee signature log and submit this with any audited claim or use an attestation statement if a signature was inadvertently omitted.

Practitioners should be able to review the options for signatures on their local carrier’s website. A practitioner who has any doubt about the legibility of the signature on documentation should send in the signature log or an attestation statement.

When an audit notice is received

Once practitioners have received a prepayment review request, they have 30 days to send in the records, diagnostic test results, and any other information pertinent to the claim.

Always carefully review any records sent in for audit. If an error is found, the only proper way to correct an error is to add an addendum to the examination.

The addendum should be clearly written, dated and signed so there is no question when it was added. Ideally a practitioner would never need an addendum if the chart is carefully reviewed at the end of the day to ensure completion.

Palmetto plans to post results of its audits on its websites. Another large Medicare carrier, Wisconsin Physician Services, already has. Other carriers may do the same.

If individual practitioners are found to have significant deficiencies in their documentation, those practitioners will receive one-on-one education to correct the errors.

The AOA Third Party Center has already received numerous reports of auditors across the nation denying payment for (what most practitioners would probably consider) well-documented and appropriately coded examinations and procedures.

Every practitioner must now be thorough in providing complete documentation for all services.

Documentation for each patient encounter must be properly signed by the practitioner with the date of the encounter and the patient clearly identified.

The new prepayment audits represent just one part of an overall effort to ensure greater accuracy in Medicare claim filing.

Across the nation, the Comprehensive Error Rate Testing (CERT) audits and Recovery Audit Program (RAC) audits are increasing. CERT auditors have been known to deny all claims presented for audit even with appropriate, complete documentation.

These audits can result in repayment requests that extrapolate the claims to cover the entire audit period and can result in recoupment demands of as much as $900,000.

While practitioners typically have 30 days in which to respond to an audit request, the CERT and RAC auditors do not have a time limit in which to send the results.

The AOA Third Party Center Executive Committee has received reports of audit results being returned 14 months after the requested claims have been submitted.

All practitioners have the right to appeal any negative audit decision they receive. However, there are many steps in the appeals process and practitioners must respond in a very short time period if they wish to begin an appeal and prevent the recoupment process from moving forward. Appeals can and should be made when a negative result is received.

History has shown that negative audit findings can be reversed on appeal.

However, the most practical course of action is for optometrists to make sure claims are filed correctly and properly documented in the first place.

The AOA and its affiliated state optometric associations are monitoring this new prepayment review program carefully to ensure optometrists are not improperly denied payment.

Practitioners are asked to report any audit notices they receive – as well as the results of any audits – to their state optometric association’s Medicare Carrier Advisory Committee (CAC) representative and the AOA Advocacy Group.

Information can be relayed to CAC representatives by contacting the state optometric association.

Information regarding audits can be sent to the AOA Advocacy Group at RPeele@aoa.org.

AOA members can obtain information on proper coding through the association’s Coding Today website (http://aoacodingtoday.com).

AOA Medical Records Consultant Chuck Brownlow, O.D., and the association’s Ask the Coding Experts service are available to respond to specific questions from AOA members regarding the proper use of billing codes.

Coding questions should be directed to askthecodingexperts@aoa.org.

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