Commonly occurring issues in coding and coverage require being involved.

Those of us who deal with retina patients run onto a different set of coding issues and regulatory oversight than other specialties in eye care. We have spoken about the most common of these before, but let’s review them in a single column. We’ll also address the newly approved Medicare Advance Beneficiary Notice of Noncoverage (ABN), which must be used as of Jan. 1, 2021, for Part B Medicare when required.

I have listed these issues below in no particular order of importance to payers:

Retinal anti-VEGF drug costs

Drug costs are real to payers and patients alike, and even to you. Many of you are responsible for the ordering and tracking of these, so it is important you intimately understand the actual dollar cost of “losing track” or not getting paid adequately for every vial.

In ophthalmology, more than one third of the total reimbursement to the entire specialty goes to only a few drugs. Additionally, many private payers have imposed “fail-first” or step therapy, although that is not imposed in Part B Medicare at this point. We wrote about step therapy in a prior OP column (bit.ly/Coding719 ). Know which payers have those policies and document appropriately the rationale so that you can support medical necessity if your provider needs to circumvent them. Failure to do so risks the reimbursement for those more expensive drugs.

Investigate coverage and polices in advance and keep on top of them. Have a robust inventory system to manage this large outlay.

Modifier 25 appropriate use

Modifier 25 oversight remains an issue. Payers do not want to pay for exams that should not be reimbursed. Repeated audits show it is a difficult issue for most specialties to manage – not just eye care. An Office of the Inspector General (OIG) report from 2002 had an error rate of 35%; my personal experience as a certified auditor is that this number hasn’t budged.

If you have questions on how to properly apply modifier 25, it was the subject of another previous OP coding column (bit.ly/Coding715 ).

Insufficient documentation for services billed

Another official government report in 2019 noted that when there was an identified improper payment, the category of “insufficient documentation” accounted for 57.9% of the problem. Medical necessity documentation (or rather the lack of it) accounted for an additional 20.9%.

It’s important to “think like the payer would” when you are documenting as a technician or scribe so your charts can withstand any payer reviews that happen later. It may seem difficult to do that, but your EMR can help by creating appropriate templates. Get your billing and compliance team to help as this may come more naturally to them.

Prior authorizations

Prior authorization of Medicare services for retina providers has not materialized like it has recently for hospital outpatient departments for common oculoplastics services. That means that unless there is a payer policy governing it, medical necessity will win out. For private payers, prior authorization for exams and drugs (and even some tests) is de rigueur for many plans. Your documentation when seeing the patient before those services or drugs are actually used is key to “winning the support” so that the patient gets timely and appropriate care based on your doctor’s advice. You already deal with this on prescriptions — it has expanded even more into everyday office visits — and is likely to become MORE common instead of less, so be prepared in advance for these and chart accordingly.

New ABN

CMS finally has the new version of the ABN form. You can access the CMS form and instructions for use at go.cms.gov/2XS49uL .

CMS was careful to note the following in boldface type: “... Due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023). At this time, the renewed ABN will be mandatory for use on 1/1/2021. The renewed form may be implemented prior to the mandatory deadline ...” If you are unsure of when (or when not) to use an ABN, another previous OP article covered that (bit.ly/Coding516 ). An incorrect or expired form could be considered invalid, so be sure you understand the important differences.

Summary

Be aware of how payers think, and chart appropriately. When people tell you it’s OK to do something that makes you uncomfortable, perform your due diligence by asking a few questions and investigating payer policies. While they might be correct in their advice, you might also arrive at a different, correct, and defendable answer for your employer. Use the new ABN form, and dispose of all old versions.

Lastly, I want to tell all readers to be safe. Protect yourselves and your patients. We’re all in this together! And, as always, “good coding to you.” OP

REFERENCES:

1. Corcoran S. CODING Q&A: Audits Increase as Injections Increase. Retinal Physician. July 1, 2019. https://www.retinalphysician.com/issues/2019/july-august-2019/coding-q-amp;a-audits-increase-as-injections-incr . Accessed July 31, 2020.
2. US Department of Health and Human Services. 2019 Medicare Fee-for-Service Supplemental Improper Payment Data. Table B3. https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf . Accessed July 31, 2020.
3. CMS. Final Rule: CMS-1717-FC. November 12, 2019. https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf . Accessed July 31, 2020.