Back to Basics

Ryan Ames, OD, MBA

InSight Eye Care, Oshkosh, WI

A little over a year ago, a wave of letters from United Health Care (UHC) started showing up in doctors’ mail boxes across the country. And to no one’s surprise, another wave appears to have just been sent out. This letter’s intent is to show doctors their distribution of comprehensive (920×4) and intermediate (920×2) ophthalmological services and compare the doctor to their colleagues. Thus far, every letter has stated that the doctor has a “high use of comprehensive ophthalmological codes.” They then go on to “define” what that code means. The letter later states they “may conduct a further review.” That certainly sounds like the threat of an audit.

Looking different from your colleagues is not a bad thing, if there is a reason for it. This reason could be that you have a more geriatric practice and see a lot of AMD and glaucoma, so your office visits are more complicated. Or a pretty reasonable explanation is that you have been billing correctly, and your colleagues are under-coding. In either case, it is fine if your documentation supports the medical necessity for the exam that was done and it also supports the office visit code that was billed. If your documentation is accurate, you will survive an audit. Every 99000 and 92000 code has documentation requirements that must be met to use it. Per CPT, here are the requirements for the 92000 codes:

Within the letter from UHC, they list these same requirements for a comprehensive ophthalmological service, but they assert that the ophthalmological examination requires dilation. Dilation is not part of a comprehensive ophthalmological service according to CPT. However, individual payers can have differing definitions of certain services as part of their contract. It would be a good idea to pull your contracts and make sure you are compliant. If a payer is requiring something different from the CPT definitions, it should be clearly laid out in the contract. If you ever find yourself in an audit and the requirements of individual codes come into question, you first need to reference the CPT definition and then your contract with that payer. If the signed contract does not have a different definition than CPT, you would default to the CPT definition.

As the number of audits increases, it is more important than ever to make sure your documentation is complete. There is no “close enough” when it comes to the requirements of the codes. If just one element is missing, you do not meet the definition of the code and it cannot be used. That’s why performing friendly internal audits throughout the year is a wise practice.

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