Are your coding habits up to snuff? AOA HPI provides benchmark data
To assist optometry practices’ billing and coding habits to accurately reflect the services documented, a new AOA resource offers optometry-specific evaluation and management (E/M) coding benchmark data.
Recently published by the AOA Health Policy Institute (HPI), a paper, titled, “Trends in Procedures Provided to Medicare Beneficiaries by Doctors of Optometry,” provides descriptive epidemiological claims data analysis of the most common services codes used by doctors of optometry. These data can help optometry practices benchmark themselves against the 2018 national average as the Centers for Medicare & Medicaid Services (CMS) continue efforts to educate physicians regarding proper billing for E/M services.
Per data from Medicare’s Physician and Other Supplier Public Use File, the HPI analysis identified more than 3.1 million E/M services reported to Medicare by doctors of optometry in 2018 with an additional 127,080 allowed (covered) 99XXX services reported outside the E/M code range specifically analyzed by the HPI paper. Specifically, the analysis noted the most frequent E/M codes were:
- New Patient Code – 99204 with 176,183 total visits.
- Established Patient Code – 99213 with 1,451,926 total visits.
Access the HPI analysis for a complete rundown of allowed services total visits for the 99201-99205 and 99211-99215 codes, including percent usage by code. Users should keep in mind that the available data are not risk-adjusted and do not account for the differences in underlying severity of disease of patient populations treated by providers.
“The Health Policy Institute performed an analysis of claims data of over 3 million E/M services reported by doctors of optometry in 2018 and it was gratifying to see, once again, how doctors of optometry are taking seriously their role in providing medical eye care to Americans,” says Steven Loomis, O.D., AOA HPI chair.
“The HPI believes that this is excellent normative data for doctors of optometry interested in benchmarking their own claims practices.”
In comparing nearly identical 2016 and 2018 percentages of E/M coding procedures provided to Medicare beneficiaries by doctors of optometry, the HPI analysis suggests the profession has “a solid understanding of E/M coding procedures.” This is particularly crucial not only as new E/M code changes are slated to take effect Jan. 1, 2021, but also as the CMS has devoted significant efforts to ensure proper coding.
In 2012, the Health and Human Services Office of the Inspector General (OIG) issued a report that found 42% of claims for E/M services in 2010 were incorrectly coded—both upcoding and downcoding—and 19% lacked appropriate documentation. The OIG further warned the CMS that physicians of all types might increase billing of higher-level, more complex and expensive E/M codes. In response, the CMS issued a guide for E/M services as well as FAQs and compliance tips, and encouraged contractors’ greater review of E/M services billing.
“While HHS predicted that physicians of all types would likely improperly ‘upcode’ future claims, the HPI data shows that doctors of optometry did not show this trend between 2016 and 2018,” Dr. Loomis says.
E/M code changes: Attend an upcoming webinar
Continuing its goal of reducing physician burden and improving the accuracy of payments for E/M visits, the CMS will implement new E/M office visit codes starting Jan. 1, 2021. These changes will delete CPT 99201 in 2021, permit doctors to choose the E/M visit level based on either medical decision-making or total time and change medical decision-making criteria. To prepare for these changes, the AOA invites doctors to participate in an upcoming webinar.
What: E/M Code Changes: Time
When: 9 p.m. ET, Tuesday, Oct. 20
Register to attend this webinar. Registrants will receive a confirmation email containing information about joining the session.
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Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.