Keep an eye on Ophthalmology Billing


Learn the nuances of billing these ophthalmology services and reduce your compliance risk.

When I first started working in ophthalmology, I worried I would become bored: I mean, after all, it’s just two little eyes, right? I quickly learned how complicated ophthalmology can be and that there are many nuances and layers to coding and billing ophthalmology services correctly.

If you have been following along in the ophthalmology world, like me, you have noticed significant changes over the past several years, which have added to the difficulty. Most of these changes center around payers’ perceived compliance risks for covering certain services.

In a 2015 publication, for example, the Office of Inspector General (OIG) noted that Medicare covers ophthalmology procedures for many eye conditions, but the two eye conditions for which Medicare pays the most each year are wet age-related macular degeneration (wet AMD) and cataracts. In 2012, Medicare paid 44,960 providers $6.7 billion for ophthalmology services for these two conditions.

Ophthalmologists must also address their own compliance risks for providing these services. In this article, we’ll focus on how to ensure compliant cataract coding without losing sight of your practice’s bottom line.


Know the Nuances

Currently, there are multiple ongoing investigations into improper billing and co-management in ophthalmology with cataract surgery. Why, when coding for cataract surgery is typically straightforward? Because cataract surgery is heavy in its nuances outside of coding. To remain compliant, we need to employ best practices in our providers’ documentation and education of all staff, as well as patients.

A standard cataract surgery is covered by payers with the patient owing only a co-pay and/or deductible. But there are lens upgrades the patient can choose for enhanced vision outcomes that are not covered. These upgrades must be paid out of pocket; and this is where education and documentation come into play.


Patient Education Is Key

I typically use an analogy when explaining this situation while working with teams. I relate coverage to shoes because, well, shoes are wonderful. Payers pay for standard, no-name shoes. There is nothing wrong with those shoes — they function well. But as a consumer, I like more comfortable and/or stylish shoes. I believe I should be able to live my life in Jimmy Choo shoes. I don’t want regular shoes. But if I want the Jimmy Choo shoes, I need to pay extra for the Jimmy Choo experience. That is how payers relate to the upgraded lenses. If I want vision enhancement as a patient, I need to pay for the upgrade.

Patients need education concerning upgraded lens choices, which then needs to be well documented. But it’s important to remember that you may NOT charge for the use of sophisticated technology. You can only charge for vision outcomes. Payers don’t care if you use state-of-the-art technology. If you are doing a standard cataract surgery, you cannot charge more for using newer technology.

Education on what different packages contain and documentation of the patient’s lens choices are almost as important as informed consent. But it doesn’t end with the documentation: Your staff also needs to understand the different packages and how to explain them. There have been so many times that I have heard healthcare professionals explain that a charge was for the laser, when really it was for the correction of astigmatism. An uneducated team can put a practice at increased legal risk.


Reduce Compliance Risk

Here are some best practices for reducing your risk when performing cataract surgery and the services leading up to them:

  • Co-management: All patients should choose whether they want their surgery to be co-managed. Never automatically send them back to the referring optometry doctor (OD).

º    Have the patient send a consent acknowledging their desire to have their post-op care — if their condition allows it — performed by the referring OD.

º    Make sure your provider documents that it is safe to return the patient to the OD.

º    If your OD refers a patient to a cataract surgeon, then make sure to document that the patient was given choices of who to go to; don’t send all your referrals to the surgeon that treats your practice the best. All patients deserve a choice.

  • Lens choices: Many surgeons offer various packages outside of the standard lens covered by insurances.

º    Document the patient’s education regarding the types of services offered and the potential outcomes for each.

º    Make sure the patient knows exactly how much they will pay out of pocket.

º    Never charge for technology: Only charge for visual outcomes. If you are not charging for visual outcomes, then you need to change your policies.

–     Example 1: An 87-year-old patient seeks treatment for her cataracts. She chooses standard lenses. The practice shows her a video on how much safer the laser is over her physician’s hands, and they tell her the laser is not covered by insurance. If the physician offered the laser and the patient gets a standard lens, you cannot charge for the use of the laser; you cannot bill for technology.

–     Example 2: A 67-year-old patient seeks treatment for his cataracts. He is an avid sportsman and has been reliant on glasses. He chooses a multifocal lens and laser treatment for his astigmatism so that he will be less reliant on glasses. In this example, you are allowed to charge for the treatment of the astigmatism that is done by laser.

  • ABNs: You do not need to have a patient sign an Advance Beneficiary Notice (ABN) of Non-coverage form (CMS-R-131) for upgraded lenses and treatment of astigmatism.
  • Education: I can’t say it enough: Educate, educate, educate. An informed patient is a happy patient. An informed staff member can answer patient questions, which keeps the patient happy. I provide education on cataracts in this way:

º    Have a surgeon explain to coders each treatment and how they differ.

º    Educate staff about Medicare and other payers’ coverage. (Feel free to use my shoe example!)

º    Educate the patient every step of the way. Remember to empathize. What is routine to you is the first time for the patient. It takes five times of hearing something for the human brain to retain it. Make sure your processes are well documented at each step.

  • Complaints: Log all patient complaints. This will give you a good way to monitor whether training is sticking and address any new concerns as they pop up.
  • Policies: Develop robust policies and procedures and put them into action.
  • Follow-up: Utilize a secret shopper to ask cataract questions and document responses.

•   Audits: Audit medical record documentation and policies to uncover noncompliance.

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