June 16, 2023 | By Rhonda Buckholtz, Owner, Coding and Reimbursement Experts
Cataract surgeries are the most commonly performed procedure in ophthalmology, and there are many nuances when auditing that you need to keep in mind. If you stay current on the legal cases that are published, you will see that co-management of cataract surgery is a hot topic, and the government has very clearly documented what they expect. Add to that the complexity of being able to add upgraded lifestyle outcomes as a cash service and you have an environment ripe for making mistakes if you don’t clearly understand those nuances.
Most often, I see where auditors failed to look to make sure that all the documentation for cataract surgery and co-management are documented and completed. Most stop at the coding, and that can lead to inaccurate results and trends that make the practice stand out from their peers.
If you are auditing in ophthalmology, you need to make sure you understand all the nuances. The Office of the Inspector General (OIG) has issued guidelines aimed at helping healthcare providers avoid compliance concerns when co-managing cataract surgeries as well as upgraded lifestyle choices.
You want to check to make sure you have developed a comprehensive list to check when auditing. Let’s start with the basics:
- All payers have requirements, be sure to know exactly what documentation they require for proof of medical necessity. Most require at least:
- Visual acuities (testing on how progressed the cataract is)
- ADLs (how is the cataract affecting quality of life and daily duties)
- Patient’s desire to have the cataract removed
- Cataracts require diagnostic testing. For cataract consults, check to make sure there is an order for the testing and that testing on a new patient is not done prior to a physician evaluating. Many times, surgeons like the idea of standing orders, which is not allowed
- Consent — If patient is having surgery, make sure informed consent is clearly documented
- Complexity — Does documentation support a complex cataract if billed?
- Statements on trypan blue use or additional time is typically not enough to meet payer requirements
- Co-management — If co-management is documented (the patient is being managed post-operatively outside of the practice), you must make sure there is clear documentation of:
- Patient’s choice — Why they want to back to their OD. Make sure there is clear documentation that demonstrates why the patient chooses, such as travel time, convenience, surgeon availability, and that they were given options
- Documented consent for co-management (separate form)
- Transfer of care — OD agrees in writing to take on the post-operative care
- Surgeon has determined and documented that the patient is stable enough to be transferred to the outside OD
- Check to make sure the correct modifiers are billed as well as the correct number of visits the surgeon had
Nuance: Some surgeons consider it a standard of care to re-evaluate the contralateral eye before determining the final need for surgery of that eye. That visit typically happens in between and is billed with a modifier -24. When auditing that visit, you must:
- Check to make sure at the original consult that it was not documented that both eyes were consented for surgery at that visit and that they would re-evaluate the second eye after the first surgery to determine best plan.
- The exam with the Modifier 24 clearly indicates a new plan for surgery and consent.
The other risky area we need to make sure we check for documentation is upgraded outcomes. This has been a large focus of investigations. There is constantly evolving technology, in both equipment and in the choice of lenses. Medicare does not pay for the use of special technology, if it is used, it cannot be charged in addition for standard cataract surgery. Many patients like the opportunity to see better or rely less on glasses and want to have the options to upgrade.
If auditing a surgery that includes the charges for a type of laser with monofocal lens, be sure that astigmatism is clearly documented and that the patient chose to have that corrected. If no astigmatism is documented there can be no charge. In addition, for any upgraded outcomes, make sure there is complete documentation to demonstrate:
- The patient understood that they can have standard cataract surgery that is covered in full (minus any deductibles or copays) by most insurance companies. They do not have to purchase an upgraded outcome.
- That the patient was consented for the technology and clearly understood their options (many practices will use a form that shows them all and have the patient initial by their choice)
- That there is not documentation that would support that charges are for the use of technology with no upgraded outcome.
Ophthalmology is never boring when auditing, there are many nuances that you need to make sure you understand and incorporate into your auditing routine. Adding the items listed will help you do a more thorough audit that focuses on more than just the coding aspect that will help your practice stay compliant.
Your next steps:
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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