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Medicare billing issue

Posted By Chet Seward, Friday, April 13, 2018

CSEPS encourages all our members to proactive in reviewing their own documentation to make sure it consistently meets the payer requirements. Members should be aware of a recent notice from the American Academy of Ophthalmology (AAO) regarding issues affecting physicians in four states.

AAO writes, “Ophthalmologists in North Carolina, South Carolina, Virginia and West Virginia, whose comparative billing report puts them in the 80th percentile, with greater than $10,000 of allowed charges and more than 30 beneficiaries undergoing an exam plus cataract or complex cataract surgery from January - December 2016, are asked by the Medicare administrative contractor Palmetto to provide the answers to specific questions. Depending upon the answer, the physician's documentation may be directed to target, probe and educate (TPE) review. They are given 1 week to respond to the following questions:

  1. Is there documentation present for all dates of service billed and or operative eye billed?
  2. Is patients own assessment of functional status causing him / her to seek medical attention?
  3. Is there evidence of a comprehensive eye examination and ocular examination and a single diagnostic a scan to determine the appropriate lens?
  4. Is there documentation indicating that the cataract is significantly contributing to the patient’s visual impairment in the presence of one or more concomitant ocular diseases?
  5. What are your self-auditing methods?”

While these TPE reviews are not  happening in Colorado, take this opportunity to be aware of trends in other states and then review the latest local coverage determinations by Novitas here. For more information, contact Sue Vicchrilli, COT, OCS, AAO Director, Coding & Reimbursement.

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