Medicare Audits Continue…Reason for Visit is Frequent Target

by Dr. Charles Brownlow

Medicare contracted auditors are picking up the pace of their audits, often finding errors in the codes that are used to report patient visits. The codes are chosen based on the content of each records, measured against the definitions for the services in Current Procedural Terminology (CPT, American Medical Association), and, in the case of the 99000 series office visits, the Documentation Guidelines for the Evaluations and Management Services.

Accurate choices of visit codes is a straightforward process, as is reflected in the fact that most electronic health care software will automatically choose office visit codes, based purely upon the content of each record. Unfortunately, possibly partially due to the ease of recording data in EHR, Medicare is seeing a rising number of higher level 99000 codes billed. It is the increase in the frequency of the high level codes that was partially responsible for the current round of audits.

By doing hundreds of ‘friendly audits’ for eye doctors over the past fifteen years through PMI “Chart Review” service, we’ve known for a long time that doctors tend to under code visits, possibly due to a fear of audits or uncertainty as to how to accurately choose codes. EHR codes correctly, which often means higher than the same doctor coded prior to using EHR.

Sadly, the accuracy of code choice may be pretty good yet the audit may still be pretty bad. The auditors are focusing upon the appropriateness of care in addition to the accuracy of the code itself. For example, a medical record may “earn” a high level of code due to an expansive case history and a physical examination filled with lots of tests and yet be rejected by an auditor because the reason for visit did not support the need for all those questions in the history and all those tests in the examination.

Again, the importance of good records and accurate coding comes to light but most important, the auditors are emphasizing the very basic premise of all health care; that it should be focused on the needs of each patient and upon the needs of the doctor providing services to that patient during that particular visit. In short, if you have redone a thorough case history on a patient that was in the office 48 hours earlier, it may have been due to habit or internal office protocol, rather than the needs of the patient or doctor. If that’s the case, it is important to grade the visit based only upon the elements of the record that were germane to the visit and necessary for care of the patient.

If your records all look the same, regardless of the unique needs of each patient and doctor at each visit, you can expect to have problems in an audit. This trend should result in a “wake up call” or all health care providers and their educational institutions that we need to return to a clear focus upon the needs of the patient at each visit, customizing the components of each visit to those needs. It is the way health care was provided in the years before insurance or Medicare and it is the way health care must be provided in the new millennium.

AOA Gets “Answer” Regarding Rejections of Ophthalmological Visit Codes

A programing glitch that has resulted in the improper rejection of numerous Medicare claims with ophthalmological established patient exam codes 92012 and 92014 will be fixed system-wide by October 1, according to the U.S. Centers for Medicare & Medicaid Services (CMS).

The programing error has resulted in the rejection of 92012 and 92014 claims with modifiers –24, –25 and –59. Eye care practitioners began noticing the improper claim rejections in early July, according to the AOA Advocacy Group. The Medicare claims are being rejected due to computer system issues associated with new National Correct Coding Initiative (NCCI) edits.

At least one Medicare administrative contractor, Noridian Healthcare Solutions, LLC, has implemented a temporary fix in its computer system to address the issue. To be safe, practitioners will have to resubmit the improperly rejected claims after October 1 in order to receive payment, according to CMS officials. Medicare administrative contractors will not automatically reprocess the claims, they emphasized.

The AOA Advocacy Group suggests practitioners hold any new Medicare claims with the 92012 or 92014 exams codes and the –24, –25, or –59 modifiers until after October 1.

OOA Third Party Bulletin September 2013

The Affordable Care Act (ACA)

The ACA requires all employers to notify their employees of the opening of the Marketplaces/Exchanges by October 1. The OOA sent an email September 18 about this. Click here for the correct link to the Dinsmore article.

The ACA continues to be confusing and “evolving”. There are several issues that this committee is attempting to clarify. In the near future, Mr. Cornett will have a meeting with key executive for insurers in Ohio. The purpose of this meeting is to lay the groundwork for the OOA to become a friendly advisor to these companies on eye and vision issues. This is a new approach. This is a huge step forward in terms of trying to obtain some consistency in the interpretation of the ACA and other issues. We are working hard on getting clarification but we don’t always control the agenda. Look for more on this in future bulletins.

*OOA Executive Director Rick Cornett and Consultant Mark Ridenour will give a one-hour presentation “An Update on the Affordable Care Act” Saturday, October 5 at 7:00 a.m. at EastWest Eye Conference. Register online at

Small Business Employer Update/ACA

The ACA defines small business as having 50 or fewer full time equivalent (FTE) employees and provides THE OPTION to purchase group insurance via the “Exchange” or “Marketplace”. IF you have fewer than 25 employees and if you choose to cover at least 50% of their health insurance premium AND average salaries are less than $50,000, you can receive a business credit. There is a sliding scale. More information can be found in the latest issue of Perspectives, online by clicking here or contact your insurance agent/broker.


AOA website has information about new HIPAA requirements including a manual to download at no charge. Click here for more information.

*Dr. Chuck Brownlow will present a one-hour HIPAA Update Friday, October 4 at 2:00 at EastWest Eye Conference. Register online at

Laws Concerning Forces Discounts on Uncovered Services

Many of you are aware that some state legislatures are considering laws that present insurers from forcing providers to give additional discounts on non-covered items. There is a bill in the Ohio legislative process that clarifies this for Ohio providers. The OOA is monitoring this legislation.

OOA Supports Ohio Department of Aging Falls Prevention Campaign

The OOA is listed as a supporter on the Ohio Falls Prevention Resources Page. Click here to view the page.

Essential Health Benefit for Children

Dr. Brownlow shared the following question from an Ohio doctor:

A mother of two children presented with Medical Mutual for medical insurance and VSP Access plan. The doctor is running a kid’s special for school and had her pay a discount price. Someone from Toledo, OH area told her that with Obamacare all kids under 21 get free eye exams. My understanding is the free eye exam starts January 1, 2014. Can you clarify?

Dr. Brownlow’s response:

First, it’s not a “free” eye examination. The law states that ever medical insurance plan must include a benefit covering children’s eye examinations and glasses if needed. It’s just like all other insurance…it may be free or less expensive for the patient or the patient’s family because insurance is paying all or part of it, but it is not free. The provider will be paid by the insurer with any deductibles or co-pays paid by the patient or patient’s family. Also, the benefit does not go into effect until October 1, 2013 at the earliest and reimbursements to providers will be a matter for negotiation and contract, just like reimbursements for all other services.

OOA Third Party Committee: Dr. Rod Snow, Chair; Dr. Nathan Bjork; Dr. Rob Engel; Dr. Lee Favede; Dr. Heath Gilbert; Dr. Larry Gill; Dr. Steve Hansen; Dr. Jay Henry; Dr. Mark Horvath; Dr. Jason Miller; Dr. Pete Mogyordy; Dr. Michael Ringel; Dr. Bill Rudy; Dr. Dave Shilling; Dr. Steve Shroder; Dr. Ted Smiley; Dr. Brent Swartz

Diabetes Awareness Month – How will you prepare?

by Dr. Beth Muckley, OOA Trustee

Diabetes Awareness Month is November. What are you going to do to promote diabetes awareness in your office?

With the increasing prevalence of diabetes, the number of Americans with diabetic eye disease is on the rise. The National Eye Institute (NEI) estimates that 7.7 million people ages 40 and older have diabetic retinopathy, and this number will increase to 11 million by 2030. Diabetic eye disease can lead to vision loss and blindness; however, early detection, timely treatment, and appropriate follow-up can prevent 95% of severe vision loss from diabetes.

The Ohio Optometric Association would like to help you promote diabetes awareness in your office. There are multiple opportunities for to grow their diabetic practice and gain referrals for diabetic examinations. Consider the following:

1. Contact all primary care physicians and internal medicine doctors in your area. Let them know you provide dilated eye exams to diabetics and you are taking new patients. Many PCPs refer to ophthalmologists because they don’t think ODs are dilating their patients.

2. Send correspondence to your diabetic patient’s primary care physician detailing your exam, whether they referred the patient to you or not. The more communication you provide, the more likely they are to send you new patients and not redirect your established patient to an ophthalmologist. AOA has a PDF report form available to members on their website for your use if you don’t want to dictate an individual letter.

3. Call your local hospital or large internal medicine clinic. Many larger wellness facilities have an ongoing diabetic outreach/education program. Ask them to refer patients to you for diabetic eye exams. Take them your business cards and brochures. They may also invite you to serve on their panel as an advisor or even provide mini-education on diabetic eye health at their fairs and public education meetings.

4. Advertise on social media sites (Facebook, office web page, etc.) that you manage diabetic eye disease.

5. Visit the National Eye Health Education Program website and sign up for webinar programs to learn more about diabetic eye disease and opportunities to help raise awareness. NEHEP has an array of resources to assist its Partnership and other intermediaries in their educational efforts including a new Social Media Toolkit, info-graphics, public service announcements, educational materials, and more.

6. Visit AOA’s dedicated Diabetes & Eye Health web page ( It provides members with information, tools, and resources to assist in providing the best level of care for their patients affected by diabetes.

Diabetes is a growing health crisis where optometry plays a critical role in its management. The landscape of healthcare is changing. It is important that you, as an optometrist, are included in caring for those that may be going towards a medical home or accountable care organization. As outcomes in patient centered homes are evaluated, making a few of the above simple steps will help you build this part of your practice and put optometry at the forefront of diabetic eye care.

2013 President’s Night – Mark Your Calendars!

2013 President’s Night will offer one hour CE on Practical Applications for ACA, HIPAA, ACOs and other health care changes. Rick Cornett will review ACA, HIPAA, ACOs, Essential Benefit, Inter-professional communications, as well as other patient centered innovative opportunities. Welcome incoming OOA President, Dr. Lee Favede.

Zone 1

Monday, September 16 @ 5:30PM

224 Varsity Club – 3598 Bullhead Rd. – Willard, OH 44890

RSVP: Dr. Jon Cooperrider –

Zone 2

Wednesday, October 23 @ 6:00PM

Ristorante Chinato – 2079 E. 4th St. – Cleveland, OH 44115

RSVP: Dr. Troy Bornhorst –

Zone 3

Wednesday, September 18 @ 6:15PM

Ken Stewart’s Grille – 1970 W. Market St. – Akron, OH 44313

RSVP: Dr. Jessica Simon –

Zone 4

Thursday, September 12 @ 6:30PM

Michael Alberini’s – 1140 Boardman Poland Rd. – Youngstown, OH 44514

RSVP: Dr. James Kover –

Zone 5

Tuesday, September 17 @ 6:30PM

Theo’s Restaurant – 632 Wheeling Ave. – Cambridge, OH 43725

RSVP: Dr. Charles Fornara –

Zone 6

Tuesday, October 15 @ 6:30PM

Athens Country Club – 7606 Country Club Rd. – Athens, OH 45701

RSVP: Dr. Shane Foster –

Zone 7

Tuesday, September 24 @ 6:30PM

The Emmitt House – 123 N. Market St. – Waverly, OH 45690

RSVP: Dr. Allison Hoffman –

Zone 8

Thursday, October 24 @ 6:30PM

Buca di Beppo Rockwood Commons – 2635 Edmondson Rd. – Cincinnati, OH 45209

RSVP: Dr. Sarah Lopper –

Zone 9

Thursday, September 26 @ 6:00PM

El Meson – 903 E. Dixie Dr. – Dayton, OH 45449

RSVP: Dr. Ross Collins –

Zone 10

Tuesday, October 22 @ 6:00PM

Old Barn Out Back – 3175 W. Elm St. – Lima, OH 45805

RSVP: Dr. Chad Otte –

Zone 11

Wednesday, October 16 @ 6:00PM

Rockwell’s at the Oliver House – 27 Broadway – Toledo, OH 43604

RSVP: Dr. Bill Kegerize –

Zone 12

Thursday, September 19 @ 6:00PM

The Worthington Inn – 649 High St. – Worthington, OH 43085

RSVP: Dr. Travis Zigler –