Coding and Billing

How to Avoid Improper Payments for Office Visits Under Medicare Part B

Chris Wolfe, OD

Dr. Wolfe in the optical in his practice. Dr. Wolfe says that coding and billing for Medicare Part B requires attention to detail and a process to ensure it is done correctly.

Avoiding common coding & billing mistakes when seeing Medicare patients.

By Christopher Wolfe, OD, FAAO, Dipl. ABO

June 12, 2024

Properly coding and billing for Medicare Part B patients may be more nuanced than you realize. For that reason, I want to provide an update about 2023 CMS Comprehensive Error Rate Testing report.

For optometrists managing patients with “office visits” under Medicare Part B, understanding and addressing common billing errors is crucial to avoiding improper payments.

Insights from the 2023 Medicare Fee-for-Service Supplemental Improper Payment Data highlight several areas where we can improve our practices.

What is Comprehensive Error Rate Testing (CERT)?

CERT stands for the Comprehensive Error Rate Testing program. It is a key measure used by the Centers for Medicare & Medicaid Services (CMS) to assess the accuracy and integrity of Medicare fee-for-service (FFS) payments. The program was established to comply with the Improper Payments Information Act of 2002 and is aimed at identifying and measuring improper payments in Medicare.

The main areas where errors occur can be attributed to insufficient documentation and incorrect coding.  Let’s look at each for a deeper understanding.

1. Insufficient Documentation

a. Inadequate Documentation for the Billed Date of Service: There were 11 instances where documentation did not sufficiently support the services billed for the specific date. Optometrists should ensure that all service notes and related documentation clearly corroborate the services billed and are detailed enough to withstand audit scrutiny.

b. Missing Attestation for Unsigned Documentation: In six cases, documentation lacked the necessary attestation for unsigned records. It is imperative that all medical records are signed and attested to confirm their accuracy and completion.

c. Missing Documentation for the Billed Date of Service: This issue was found in five claims. Maintaining comprehensive records that include all patient interactions and procedures for the claimed date is essential.

2. Incorrect Coding

a. There were 141/182 errors for incorrect coding.
i. Over-coding: 18/141 (12.7% of incorrect coding errors)
ii. Under-coding: 123/141 (87.3% of incorrect coding errors)

How can we avoid errors?

Detailed and Timely Documentation: Optometrists should ensure that all services provided are documented explicitly and on the same day the service is rendered. This includes detailed notes that justify the billed services.

Regular Training on Documentation Requirements: Conduct regular training sessions for all coding and billing staff and healthcare providers to refresh their knowledge on Medicare’s documentation requirements and any updates to coding practices.

Implement Rigorous Review Processes: Before submitting claims, implement a robust review process to ensure accuracy in both documentation and coding. Utilize checklists that align with Medicare requirements to verify that each claim is compliant.

Use of Electronic Health Records (EHR): Leverage EHR systems to streamline documentation, ensure all fields are completed and reduce the likelihood of missing signatures or incomplete records.

Audit and Feedback: Regularly audit a sample of claims and provide feedback to the providers and staff involved. This helps identify common errors and areas for improvement.

By focusing on these areas, optometrists can significantly reduce the incidence of errors in billing for office visits, ensuring compliance with Medicare regulations and minimizing the risk of improper payments.

<<Click HERE to review the full report!>>

Christopher Wolfe, OD, FAAO, Dipl. ABO, is the founder of EyeCode Education and is a partner with Exclusively Eyecare, a Vision Source practice in Omaha, Neb. To contact him:

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