April 12, 2016
6 min read

All practices should implement a medical records compliance program

Medicare comparative billing reports include optometrists; audits may be next.

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I am sure most of the nation’s health care providers have heard or read about Medicare’s recent comparative billing reports, which began during the final quarter of 2015. Knowing my colleagues as I do, I imagine that many doctors of optometry whose billing practices were reviewed, as well as those who have heard about the CBRs “through the grapevine,” are wondering what will be coming next. Audits? Site visits?

First we will review what the comparative billing reports (CBRs) are and what they are not. The CBRs are conducted by a firm (eGlobalTech) on behalf of CMS. Essentially, practices are chosen randomly from among Medicare providers, and certain components of their claims are reviewed. All the data are pulled automatically from the provider’s claims. No on-site visits are involved. Approximately 6,500 doctors of optometry were the targets of CBRs in 2015.

Essentially, the reviewers compare each provider’s billing practices to claims data of other doctors of the same specialty. This round of CBRs drew data related to:

  • the general ophthalmological services (92002, 92004, 92012, 92014);
  • special ophthalmological services (92081, 92082, 92083, 92133, 92133, 92134); and
  • the evaluation and management services (99201-99205 and 99211-92015).

Results of the reviews

National results from the CBRs of optometry indicate that 92004 (comprehensive ophthalmological service, new patient) is billed 91% of the time for new patients, whereas 92014 (comprehensive ophthalmological service, established patient) is billed for 74% of established patient visits. This would seem to indicate that doctors of optometry continue to use the 92000 series of codes more frequently than the 99000 series of codes when reporting visits for Medicare patients. The report is somewhat confusing in that it is not clear whether the percentages compare frequency of billing comprehensive vs. intermediate ophthalmological services or vs. billing one of the evaluation and management services.

Charles B. Brownlow

The CBRs also included data relative to total time per visit for visits reported with the 99000 visit codes, again permitting a doctor to compare her/his time per visit with national and state data. I have no idea how the reviewers could determine how much time was spent in each visit, because that information does not appear on claims and does not appear on most patient records.

Finally, the CBRs focused on the frequency that doctors provided glaucoma patients with both visual fields and scanning computerized ophthalmic diagnostic imaging (SCODI), such as OCT, within 90 days of each other. The cover letters sent to optometrists refer to a Local Coverage Determination issued by a single regional carrier, CGS Administrators, which states: “The contractor expects use of both tests on the same day or during short intervals will be the exception, rather than the rule.”

I strongly urge providers to read the entire cover letter to get a full understanding of Medicare’s concerns relative to the provision of eye care. The letter refers to and emphasizes adherence to the only two nationally accepted resources for definitions of services and their respective codes and for submitting claims: The American Medical Association’s Current Procedural Terminology (available online for about $100) and the Documentation Guidelines for the Evaluation and Management Services, 1997, available as a free download at cms.gov.


Take-home pearls from the report

Here are some key reminders that every health care provider should glean from this report:

  • Comparing an individual provider’s use of certain codes to averages within the nation and within the provider’s state is not meant to, nor can it, provide guidance on how doctors should provide care. A review such as the CBR only compares claims across a population of providers and cannot assess what care was needed at any of the specific visits. Of course, the care provided to each patient must be specific and appropriate to the needs of that patient and the doctor’s needs in managing the case.
  • Medicare’s special attention to optometrists may be rooted in the first paragraph of the CBR cover letter: “National data analyses comparing claims for services rendered in 2010 to those rendered July 1, 2014, through June 30, 2015, indicated a 22% increase in payments totaling $1.1 billion. The number of beneficiaries seeking treatment from optometrists increased 10.7%, while fee schedule allowed amounts increased 16% during the same time period.”
  • The percentage and number of higher level 99000 codes being billed was also noted in the report: “... physicians [a term that includes optometrists] increased their billing of the two highest E/M services, CPT codes 99214 and 99215, by 17% between 2001 and 2010.” In my opinion, this finding should be tempered by two factors that have influenced previous and current coding choices: First, providers have historically underused the higher level codes, either fearing audits or due to not being confident in the rules for choosing codes. Second, the use of electronic health care records increased dramatically during that decade, many of which objectively choose visit codes based on the content of each chart, resulting in higher codes being billed.
  • The SCODI/visual fields issue may have been partially triggered by another finding during CBRs, in that, “... due to low provider utilization of glaucoma stage indicator codes [ICD-9-CM] 365.70-365.74, it was not possible for the team to determine how many of the services were medically indicated based on the disease severity. Sixty percent of claim lines submitted with a glaucoma ICD-9–CM code requiring the addition of the supplementary code to identify the glaucoma stage did not contain the required code.” In other words, poor compliance with basic rules and requirements of code reporting, including the reporting of the “stage code” with many glaucoma diagnoses, resulted in closer scrutiny of members of the profession.

All providers need to “go back to basics” in order to comply with contract requirements of Medicare and other insurers while continually being committed to the needs of each patient and to the doctor’s needs in managing each case. An insurer does not dictate what the doctor can or should do with each patient at each visit. The insurer only controls which services the insurer will pay for.

All care that is to be billed to Medicare or another medical insurer must be clearly linked to “medical necessity” by a medical reason for visit and a medical diagnosis. Chapter 12 of the Medicare Claims Processing Manual (section 30.6.1 – Selection of Level of Evaluation and Management Service) states, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”


Medicare’s emphasis on “medical necessity” and the “appropriateness” of care should not be a surprise to any providers and, it is hoped, should not necessitate any changes in the way care is provided. All providers must commit (or recommit) themselves to carefully focusing all care upon the needs of each patient. Doing so permits the doctor to provide the care the patient needs, use the correct codes when billing for that care and continue practicing confidently, knowing that the defense in a payer audit will be easily mounted. Defense will be a simple matter of reviewing the case, stipulating that all care was necessary and that all codes were chosen based on the requirements and definitions of Current Procedural Terminology and the Documentation Guidelines for the Evaluation and Management Services, 1997.

Develop medical records compliance program

Clearly, it would behoove every provider to implement a medical records compliance program as soon as possible. Compliance programs have long been required of hospitals and large medical clinics and have been (and continue to be) voluntary for small group and solo practices.

Your medical records compliance program should include education of all doctors as well as periodic internal audits of each doctor’s charts (e.g., five to 10 charts per doctor every 6 months). Education/reminders relative to medical necessity and compliance with national rules, complemented by internal audits, will permit practices to identify and address any errors in record keeping or billing in advance of any payer audit. Doing so also makes it much easier to defend one’s records and coding choices if and when faced with an audit.

I know of no shortcuts to the provision of appropriate care, good medical record keeping and accurate coding. It is critical that any offices that are less than fully confident in their compliance take action to become so, via development of and commitment to a compliance program. The alternative may be an ugly audit and huge payments to Medicare and other insurers, possibly made even worse by associated fines and penalties. There are no viable alternatives to doing things correctly and certainly no viable excuses for not adhering to definitions, rules and guidelines that have remained largely unchanged for nearly 2 decades.

Disclosure: Brownlow is a health care consultant with ForeSight, LLC.