Who in the medical practice is ultimately responsible for proper documentation and correct coding?

Office of Compliance and Corporate Integrity

Billing and coding compliance is the role of everyone involved in the delivery of healthcare. Compliance monitors coding and billing strategies and audits medical records to guarantee that documentation supports the information reported in medical claims.

Compliance with the standards of accurate coding and claims submission is paramount to the success of the medical practice to ensure that the health care reimbursement system functions transparently without fraud or abuse. Fraud is defined as billing for services that were not delivered. Abuse is defined as billing for services that are billed inappropriately.

Billing and coding compliance revolves around making sure that what is in the patient’s medical record is accurately transcribed into industry-standard medical code. The medical practice is ultimately responsible for the accuracy of claims filed for services provided and physicians are held responsible for the accuracy of information coded on a claim or bill. Therefore, services must be reported in accordance with reporting guidelines and instructions and every effort made to ensure that coding is accurate.

Morehouse School of Medicine and Morehouse Healthcare comply with all applicable federal and state health care billing laws and regulations. We ensure that services provided are consistent with applicable statutes, regulations and program requirements involving federal and state health care programs including guidance issued by the Office of Inspector General, Department of Health and Human Services, and other government regulatory agencies including guidance and the requirements of the Health Insurance Portability and Accountability Act (“HIPAA”).

Morehouse School of Medicine and Morehouse Healthcare are committed to preventing fraud and abuse in billing and act responsibly in submitting only charges that are truthful and accurate, and reflect medically necessary or appropriate services that are fully supported by health care record documentation.

Additional Resources 

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Oct. 6, 2021

It’s easy to let coding software or a staff member code patient visits on your behalf. However, it’s essential that the doctor closely review all coding that is submitted. Here’s why, and what can happen when the doctor does not double-check coding.

For a doctor to become a provider for a third party (eg: Medicare, Medicaid, VSP, EyeMed), the doctor must sign an agreement attesting that accurate claims will be submitted.

It is permitted that billing specialists or even alternate sources, such as software, may help select the codes used, however, the provider must ensure that the submitted claim accurately reflects the services provided using appropriate coding. The doctor is ultimately responsible for the codes submitted to a third party for billing purposes.

Let’s say that another way. In the case of inaccurate claims, it is the provider who will be fined and/or jailed. We hear employee optometrists often say, “But I’m just an employee optometrist doing what I’m told.” Well, then consider this case that really happened. An optometrist was hired as an employee to see patients. The employee optometrist would see patients, then turn them over to the optician in the practice who completed everything needed, including coding and billing for the examination. The doctor never checked to see if the coding submitted was supported by the patient record documentation.

Medicare audited the doctor’s patient records and reported to the optometrist that the coding and billing was not supported by the patient record documentation, so the optometrist owed Medicare over $300,000 back in over-payments plus there would be additional penalties placed on the optometrist. The optometrist’s defense was “I didn’t know.” Medicare’s response was, “If you accept money from the federal government, then it is your responsibility to know.” This did not end well for the optometrist.

So, the question we are asking today is: “Do you check the coding of each patient’s record that you see to make sure, not only that the coding is supported by your documentation, but that the coding is appropriate?” Keep in mind, when you sign the record, you are stating that everything in that record, including the coding, is accurate and true. If you are signing patient records without checking the coding, then you are at risk both legally and financially for what someone else may put into that record.

That’s not a safe place to be.

If you are a student at a school or college of optometry where the coding education is not emphasized or taught well, then ask your practice management educator for access to the free coding course that has been placed within the Association of Practice Management Educators (APME) website. (This course is only available at no charge to optometry students while they are in optometry school.)

If you are a practicing doctor, then every major educational seminar across the country hosts coding courses. Coding courses are also offered online. Medicare has the CMS Medicare Learning Network. In other words, there are many coding resources available. Each year, there are changes to coding. It is your responsibility to keep up with the changes. You should spend 2-3 hours of your continuing education each year on coding courses.

It’s your responsibility to see that your patient record is accurate, including the coding. You signed a legal document with every third party for which you are a provider saying that you accept that responsibility. There’s no excuse for not meeting that agreement.

If you want to know more about the penalties that Medicare can impose, then read THIS document.

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The ultimate goal for coding and reimbursement in the retina practice is to appropriately maximize reimbursement by producing clean claims and providing audit-proof documentation. This can be achieved by a commitment to developing expert-level knowledge. Start with building an exceptional foundation and continue growing each year.

MASTER THE FUNDAMENTALS

You can develop a solid coding foundation by understanding a few essential topics in retina coding. These areas should be continually reviewed to build a solid foundation of coding knowledge.

• Evaluation and management (E/M) and eye visit codes
• Modifiers
• Correct coding initiative bundles
• Testing services
• Global periods
• ICD-10 coding rules
• Payer policies

Coding is a team sport, and each person in the practice contributes to appropriate documentation and correct coding. Although the physician is ultimately responsible, staff provide an important supporting role and, everyone should receive ongoing education related to their individual roles. Each step of the patient encounter and revenue cycle management provides an opportunity to contribute expert coding knowledge.

TEST YOUR KNOWLEDGE

Take this quiz based on specific coding scenarios to test your knowledge and see how much you know!

Questions

An established patient was seen for a follow-up evaluation of an epiretinal membrane in the left eye and proliferative retinopathy in each eye with previous panretinal photocoagulation. Fluorescein angiography and OCT were performed. The plan was to continue to observe and schedule a follow-up visit in 6 months. Based on the multiple problems and testing, would this be moderate level of medical decision making (MDM) and E/M level 4, CPT code 99214?

In the global period of a pars plana vitrectomy in the right eye, a laser to repair a retinal tear was performed in the left eye. Which modifier should you use?

When can CPT codes 92133 and 92134 be unbundled with modifier -59, distinct procedure scheduled when performed on the same day?

How frequently can CPT code 92134 be billed for a patient receiving monthly intravitreal injections?

We billed Medicaid for an office visit because the patient was 14 days status-post; we used CPT code 67228 and received a denial with the explanation that the visit was considered postoperative. Doesn’t this laser treatment have a 10-day global period?

We received the results from a Medicare audit and one of our intravitreal injections was denied as not medically necessary. The ICD-10 codes H35.3122 (nonexudative AMD, intermediate, left eye) and H35.321 (exudative AMD, right eye) were linked to CPT code 67028-LT. Why was the claim denied?1

Answers

1. The final determination for the level of E/M is based on the level of the three MDM components: problem, data, and risk. To meet an overall MDM as moderate, two of three components must meet or exceed that level. In this case, two or more stable chronic illnesses would be a moderate level problem. Additionally, the level of risk would be low with a final MDM of low, and CPT code 99213 would be appropriate.

Fundamental: For E/M code selection, consider the level of MDM for each category, then determine the final E/M MDM based on meeting or exceeding two or three categories.2

2. Append modifier -79, unrelated procedure by the same physician in the postoperative period, along with the appropriate anatomical modifier (ie, -RT or -LT).

Fundamental: Master modifiers, including surgical modifiers -58 and -78.3

3. CPT codes 92133 and 92134 are mutually exclusive and should never be unbundled. Bill the test that contributes most to the MDM on the day of the encounter.

Fundamental: Review National Correct Coding Initiative edits and the scenarios in which it is appropriate to unbundle.4

4. The answer depends on the insurance payer policy. For the Medicare Administrative Contractor, Novitas, its two policies for OCT, L35038 and A57600, state “No more than one (1) examination per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment, or in conditions suggestive of rapid deterioration.”4 For patients not on active treatment “no more than one (1) examination every two (2) months” or “in conditions suggestive of rapid deterioration.”5 Note: 1 month is defined in A57600 as every 28 days. Policies for other contractors can be found at aao.org/lcds.

Fundamental: Confirm payer-published policies for retina services provided to identify documentation requirements, frequency edits, and covered diagnoses.

5. Medicare has a 10-day global period for CPT code 67228, but some payers, including Medicaid plans, may still recognize it as a 90-day global period and a major surgery.

Fundamental: Identify the global period for all retinal procedures per insurance payer and create an internal reference guide for correct coding.6

6. Link only the ICD-10 code that supports medical necessity to the injection. Reporting nonexudative AMD as a diagnosis for an intravitreal injection may lead to a denial as not medically necessary.

Fundamental: The appropriate ICD-10 to CPT code link is crucial as it supports the medical necessity for the service reported.

HOW DID YOU DO?

Knowing how to bill for retina services correctly and efficiently is crucial in any retina practice. For more information on the Fundamentals of Retina Coding, visit aao.org/retinapm or explore the Retina Coding: Complete Reference Guide, available at aao.org/store.