Best Practices To Boost Performance On Insurance Audits

While it is unlikely that you can prevent insurance audits, there are steps you can take to ensure your billing and coding practices comply with payer rules, thereby helping you perform your best when the inevitable audit arises. Following billing and coding guidelines and proactively auditing your charts will ultimately save you time and money, providing invaluable peace of mind.

Follow the Rules

Some of the most adverse audit findings for optometrists include failure to document medical necessity before testing, inadequate documentation to support coding of office visits, and improper use of modifiers, especially modifiers -25 (separate evaluation and management services) and -59 (distinct procedural service). Let’s examine each of these.

Documentation Of Medical Necessity

Medical necessity determines whether a particular treatment, service or procedure is reasonable, appropriate and in the best interest of a patient's health based on accepted medical standards.

To ensure diagnostic testing meets the definition of medical necessity, familiarize yourself with the medical policy guidelines of each payer. Most follow the policies published in the Local Coverage Determinations (LCDs) by your local Medicare Administrative Contractor (MAC), but some payers may be more restrictive. The following are universal guidelines:

• Diagnostic testing must be ordered before it is performed. 
• Include the reason (diagnosis) for the test and clear details of the test being performed, including a timeline. (i.e., Patient to return within one-week for OCT of optic nerve, dx H40.003)
• Most tests require an interpretation and report (I&R) to be documented in the patient’s record. You can tell by the Current Procedural Terminology (CPT) description which tests require an I&R. For example, “’92133 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE”¹

The I&R should include these four R’s: 

• Reason the test was ordered
• Results of the test
• Reliability of the results
• Recommendation of continuing care.  (i.e., OCT of Optic Nerve head due to cupping OU, Good quality (include metrics of quality as produced by OCT), OCT shows borderline thinning superiorly in both nerves. Repeat 6 months.)

Coding of Office Visits

When billing office visits for eye care, there are two options to choose from: 

• Evaluation and management (E/M) codes (992XX) 
• Ophthalmological services or eye codes (920XX)

How do you know when to use an E/M code or an Eye Visit Code? It is important to understand the unique documentation requirements for the two options. 

Evaluation and Management Codes

Selection of an E/M code can be based on either Medical Decision Making (MDM) or total physician time performed on the date of the encounter. As with the Eye Visit Codes, CPT does not define the documentation of the history, but it should be medically appropriate and driven by the chief complaint. 
If the level of E/M services is based on MDM, the following should be considered:

• The number and complexity of problem(s) that are addressed during the encounter;
• The amount and/or complexity of data to be reviewed and analyzed; and 
• Risk of complications and/or morbidity or mortality of patient management

The American Medical Association (AMA) has published this MDM table to make choosing the correct code easier.

Visits that consist primarily of counseling and/or coordination of care may be best coded based on the total time spent by the provider. 2021 E&M guidelines define time as the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician in care of the patient on the date of the encounter.

Eye Visit Codes

The Eye Visit Codes for both new and established patients have two classifications: comprehensive (92004, 92014) and intermediate (92002,92012). Although CPT does not define the documentation of the history, it should be medically appropriate and driven by the chief complaint. The comprehensive exam requires 12 elements, and the intermediate exam requires at least three but fewer than 12 elements of the exam.  The American Academy of Ophthalmology (AAO) published a list of the elements that should be included in the exam in the April 2020 edition of Savvy Coder.

Dilation is included in the CPT description but is not required. However, it may be the policy of some payers to require dilation. Both the comprehensive and intermediate exams require initiation or continuation of diagnostic and treatment programs which may include prescribing medication or eyewear, ordering diagnostic testing, or scheduling follow-up care for a medical problem.

Modifiers -25 and -59
The unbundling modifiers -25 and -59 are often overused and in an audit, improper documentation can add up to trouble.

Modifier -25: “Significant, Separate Identifiable Evaluation and Management Service by the same physician or other qualified health care professional on the same day of the procedure or other service.”²

• This modifier should only be appended to E/M (992XX) or Eye Visit Codes (920XX) on the same day a minor procedure (0-10 day global period) was also performed.
• The documentation should indicate that the patient’s condition required a “separate and significant” office visit, above and beyond the care associated with the normal service to perform the procedure. 
  
  CPT rules do not require the office visit and the procedure to have a different diagnosis. However, the claim generally processes more quickly if a separate diagnosis is included. For example, if a patient presents for a glaucoma follow-up and you determine epilation, CPT 67820, is required at the same visit, you should bill CPT 992XX, modifier -25, H40.XXXX and CPT 67820 dx H02.05X. 
  
  However, if a patient presents with eye pain in the left eye that you determine was caused by a foreign body, it would be inappropriate to bill CPT 992XX, modifier -25, dx H57.12 and CPT 65222, dx T15.02XA. The foreign body was the reason for the eye pain and the office visit is bundled with the procedure.

Modifier -59: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier -59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.”³

This modifier is often used to incorrectly unbundle CPT 92250 (fundus photos) and CPT 92133 or CPT 92134 (SCODI). The Medicare National Correct Coding Initiative (NCCI) designates these CPT codes as mutually exclusive, and they should not be reported together.  If your documentation supports “a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual,”4 then you should append modifier -59. 

Learn to Self-Audit

You may have heard the saying, “Just because you got paid, doesn’t mean you billed it correctly.” Empower your biller or an associate doctor in your practice to review a random sample of charts for an internal audit. This proactive move will help you evaluate your strengths and weaknesses in chart documentation, billing and coding. Here are some questions to ask and elements to review:

1. Was the chief complaint properly documented?
2. Was a medically appropriate history and exam documented?
3. Review AAPC E/M Audit Tool for E/M codes.
4. Review AAO Comprehensive-Eye-Visit-Code-Checklist for ophthalmological codes.
5. Was documentation of medical necessity and I&R recorded for each test ordered?
6. Was the use of modifiers appropriate? If modifier -25 & -59 were used, was the appropriate documentation to support their use in the chart?

By thoroughly evaluating these areas, your practice can identify any discrepancies or areas for improvement in documentation, billing and coding practices, allowing you to take corrective actions as necessary to ensure compliance and accuracy.

Get A Voluntary External Audit

Having a voluntary external audit allows you to have an ‘unbiased eye’ review your records to determine if you are documenting and coding your charts correctly. Without risk of penalty, you will receive feedback about whether you could pass a formal audit or if you have work to do. You will also learn if you are missing revenue opportunities by undercoding — not only does undercoding mean being underpaid, but it also means your medical records are incomplete or incorrect, and that could mean trouble in an audit.

Additional Resources Available To PECAA Max Members

Billing & Coding Records Audit Program
PECAA partners with chart auditing expert, Dr. Thomas Cheezum, to provide our members with a resource to get a better understanding of how efficient their current billing is, and how they can maximize payments by improving their billing and coding procedures.

The Coding Coach
PECAA provides several Billing & Coding resources, including the Coding Coach Newsletter and Coding Coach Webinars, to bring you the most up-to-date and accurate information available. 

If you would like to learn more about the resources listed above, contact Dianne Boulay, one of PECAA’s Billing and Coding Advisors. As a PECAA Max member, you can receive expert advice from Dianne and PECAA’s other Member Business Advisors at no additional cost! Already a member? Book a meeting with Dianne here to get started. Not a PECAA Member? Contact us to learn how PECAA can help your practice thrive.