CODING & COMPLIANCE

Medicare Mishaps in Ophthalmic ASC Coding/Compliance

BY RIVA LEE ASBELL

An article in this issue focuses on the dangers of inducement. This article includes an interview with Thomas S. Crane, Esq. and reviews different aspects of inducements and compliance. Some of the issues in this review involve examples of inducement encountered in an ophthalmic ASC; others involve compliance infringements or simple errors. Some are sins of commission; others are sins of omission.

Cosmetic Procedures

Cosmetic procedures are statutorily excluded from coverage in the Medicare program. From an ASC perspective, this means it is the patient’s responsibility to pay the surgeon’s fee, the facility fee and the anesthesia fee for any cosmetic procedure. If the procedure is both cosmetic and functional then the ASC, anesthesiologist, and surgeon may bill Medicare for the functional surgery but must bill the patient for the associated charges for the cosmetic portion. Here are some examples of compliance infringements I’ve found when auditing ASCs; some are simply mistakes but when there is intent, Medicare would consider it fraud.

CLINICAL SITUATION:

Patients routinely scheduled for surgery for functional upper eyelid blepharoplasty and ectropion repair of both lower eyelids.

COMPLIANCE ISSUE:

Perusal of the operative notes reveals that bilateral lower eyelid blepharoplasties were performed. This would be considered fraud since there is intent.

CLINICAL SITUATION:

Patients routinely scheduled for surgery for direct eyelid lesion excision (CPT codes 11440-11446, 11640-11646, 67840).

COMPLIANCE ISSUE:

The coding was intentionally upgraded to CPT codes for tissue rearrangement (CPT codes 14060-14061). In this type of upcoding, the repair codes (CPT codes 12011-12018 or 13151-13153) are used.

CLINICAL SITUATION:

Use of CPT code 61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural) for cases other than those with which the code was designed to be used.

COMPLIANCE ISSUE:

Oculoplastic surgeons should use this code only when performing the specific procedure(s) developed for its use. It should not be used in conjunction with dacryocystorhinostomy or silicone intubation of the nasolacrimal system.

CLINICAL SITUATION:

A procedure covered under Medicare has to be billed to Medicare for that procedure. The procedure cannot be broken into component parts (i.e., one part billed to Medicare and the others to the patient).

COMPLIANCE ISSUE:

Upper eyelid blepharoplasty with the patient billed for removal of the medial fat pad and Medicare billed for the upper eyelid blepharoplasty.

CLINICAL SITUATION:

If two Medicare covered procedures are performed in the same session both should be billed to Medicare.

COMPLIANCE ISSUE:

An example would be performing a brow lift and upper eyelid blepharoplasty during the same session. Be sure to check your Local Coverage Determination (LCD) and if your Medicare Administrative Contractor (MAC) doesn’t have one use one of the other providers such as from Novitas-Solutions, WPS Medicare or NGS Medicare.

Hot Coding/Compliance Issues

In this section, we’ll discuss several top coding dilemmas that have potential compliance infringement implications.

Complex Cataract Surgery. There are definite qualifications that a cataract extraction with insertion of an intraocular lens must have defined in CPT and the MAC LCDs, the most important being that complications occurring during a case are not the reason the surgeon is coding the case as complex. ASC personnel do not usually question the physician’s choice of code. Be sure the indications and characteristics of the case that qualify it as complex are described clearly in the operative notes, preferably stated in a brief narrative at the beginning of the procedure description.

When the code was originally developed, it was estimated that approximately 1-2% of a surgeon’s cases would qualify as complex. The utilization, which was 1-2% in the early years, is now 8-10%. The increased utilization was noticed by CMS since cataract surgery is one of their highest volume procedures. However, there are many cases being coded as complex cataract extractions that do not qualify.

Use of the Unlisted Codes. Unlisted codes in CPT are those that end in 99, such as “67399 Unlisted procedure, ocular muscle” or “66999 Unlisted procedure, anterior segment of eye.” CPT instructions state the unlisted procedure code should be used if the exact code does not describe what was performed; however, these codes should not be used for facility coding, since Medicare contractors have no mechanism in place to have these claims evaluated and assigned a payment value.

Category III Codes (Emerging Technology Codes). Category III codes are temporary codes for emerging technologies, services and procedures. One purpose is to allow the collection of data for services and procedures that can’t be accomplished by using unlisted codes.

The codes are five digit alpha-numeric codes with the fifth digit being a letter. The assignment of codes is chronological, based on the date of approval by the CPT Editorial Panel.

Payment of a Category III code, however, is determined by the MAC, not calculated by RVU (Relative Value Units) methodology as Category I codes are. If the code isn’t confirmed for payment by your MAC, or on the ASC list, then Medicare cannot be billed for that procedure. ■