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Medicare and coding update for 2013

January 14, 2013

Edited by Chuck Brownlow, O.D., Medical Records consultant, AOAExcel

Medicare Audits

Medicare carriers continue their quest to identify physicians and suppliers who are providing and charging for unnecessary or inappropriate services as well as those who are coding incorrectly.

A report issued late last month indicated Medicare audits in fiscal year 2012, which ended Oct. 1, netted more than $6 billion in claims against physicians and suppliers. Based on that information, one can assume that Medicare audits will continue through 2013.

Many physicians have done well in audits, demonstrating that they have provided care that each patient needed, no more no less, have kept clear, thorough records of all they’ve done for each patient, and have carefully chosen procedure and diagnosis codes based on the content of each record.
It’s clear they have a thorough knowledge of the definitions in Current Procedural Terminology (CPT © American Medical Association) and International Classification of Diseases, 9th Edition.

Medicare fee schedule

As has been the case for the past several years, Medicare’s formula for calculating changes in the official Medicare Fee Schedule has resulted in a recommendation to Congress that there be an across-the-board decrease of 26.5 percent for 2013.

The Centers for Medicare & Medicaid Services (CMS), members of Congress and health care providers’ organizations have attempted to revise the flawed formula with no success.

Those annual failures leave Congress to decide whether to permit the huge decreases set to go into effect Jan. 1 or to adjust the numbers to produce no change, smaller decreases or small increases. This process usually uses most of the month of December, and some years the final fee schedule is not established until mid- to late-January.

Medicare deductible

Medicare’s annual deductible for beneficiaries will increase by $7 for 2013, rising from $140 in 2012, to $147.

Medicare’s EHR Incentive Program

Approximately 3,000 optometrists have qualified for and have received cash bonuses from the CMS for implementing and utilizing electronic health records in their offices and by attesting to ‘meaningful use’ of the electronic record program.

The total of the bonuses paid to optometrists passed $44 million in early August 2012.

Physicians who begin using electronic records after 2014 will not be eligible for the bonuses, unless the CMS decides to extend the program beyond that date.

Few changes in CPT or ICD-9 for 2013

International Classification of Diseases, 9th Revision, will be replaced by ICD-10 on Oct. 1, 2014. ICD-9 is essentially “frozen” and no new codes will be added in 2013 or 2014.

There are quite a few changes in CPT for 2013, though the only changes directly impacting eye care are additions or slight changes in the language of the definitions for several existing codes.

The only new CPT code related to eye care for 2013 is “65800, Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous,” replacing code 65805.

Forewarned = forearmed

The experience of other physicians in audits by Medicare and other insurers may provide your motivation to follow several key steps to create and sustain your practice’s medical records compliance. They include:

  • Purchase the AMA Current Procedural Terminology each year (available as a package with Codes for Optometry from AOA Marketplace).
  • Purchase International Classification of Diseases, 9th Revision each year.
  • Conduct internal self-audits of each doctor’s charts periodically; for example five charts each three months; checking for the quality of the record-keeping. This includes a clear reason for visit, legible record of elements of case history, physical examination, and medical decision-making, record of all diagnoses and management options that are related to the visit. Each record must include orders for any additional testing that is done or recommended, referrals, etc., as well as interpretations and reports of all special ophthalmological services performed during each visit, and appropriate initials, dates, and signatures throughout each chart.
  • Develop in-office protocols to be sure that all patient care is based upon each patient’s needs and that all records are clear, thorough and legible, and that all claims are completed using codes chosen based upon clear knowledge of CPT and ICD-9 definitions and standards.

2013 promises to be a very active year with respect to Medicare and other insurers’ audits of health care providers, including optometrists.

Now is the time to conduct meetings of doctors and staff in your office to be sure that you will do well in the event that your office attracts scrutiny.

It is not difficult to keep good medical records and code correctly, once your office has created and has become devoted to medical record compliance.

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