Every payor conducts audits.

Some are automated, meaning they are data-driven and involve no record review; others qualify as complex reviews and result in requests for documentation. The case scenarios presented below are true. We appreciate the practices that have shared their experiences so that others can be made aware of these common coding mistakes.


Example No. 1: Billing New vs. Established Patients

The Error: When is a patient new? When he or she has never been seen by anyone in the practice, or when it has been 3 years plus 1 day since the patient was last seen by anyone in the practice.

Changing one’s taxonomy to a retina or uveitis subspecialty designation does not change the patient’s status. If you, a retina specialist, see a patient in practice A and then see that same patient in practice B within 3 years, the patient is considered established in the practice. If an anterior segment ophthalmologist refers a patient to you and you both practice under the same tax identification number, you must bill that patient as established—even though you personally have not had a previous face-to-face encounter with him or her.

The Fix: Staff must carefully screen patients perceived to be “new to the practice” in order to avoid this error.

Example No. 2: Billing the Correct Units for a Drug

The Error: Billing ranibizumab (Lucentis, Genentech) for treatment of age-related macular degeneration as 1 unit instead of 5 units (Table 1). Neither the person doing the billing nor the person posting payments caught the error, which references the quantity of units and results in payment of a fraction of the allowable.

The Fix: An audit is helpful in pointing out this costly error. Claims less than 12 months old can and must be corrected.


Example No. 3: Mismanagement of Modifier -59

The Error: Routinely unbundling CPT code 92250 Fundus photography, from code 92134 Retina OCT. In 2011, the National Correct Coding Initiative created this bundle. The bundle indicator is “1,” which means the two codes may be unbundled under certain circumstances.

The Fix: It is appropriate to unbundle code 92250 from code 92134 by appending modifier -59 Separate procedure to code 92250 when the payor has published in writing the appropriate conditions. To view the local coverage determinations by your area’s Medicare Administrative Contractor, visit aao.org/lcds.

Example No. 4: Mismanagement of Modifier -25

The Error: Appending modifier -25 to any level of evaluation and management (E/M) service or to an Eye visit code performed the same day as a minor procedure. In a retina practice, modifier -25 can be applied to these CPT codes: 67028, 67101, 67105, 67221, 67227, and 67228 (Table 2).

The Fix: Understand the requirements of modifier -25 Significant, Separately Identifiable E/M Service (or Eye visit code) performed by the same physician on the same day as the procedure or other service to which the modifier is applied. Recognize that all new patient examinations are billable and should be paid.

Established patients: When you review your documentation, remember this: Even if a procedure is medically necessary, if the established patient examination is performed solely to confirm the need for the minor procedure, then the examination is not billable separately from the minor procedure.1

Example No. 5: Mismanagement of Modifier -25

The Error: Appending modifier -25 to all levels of E/M services and Eye visit codes when any test is performed the same day. The modifier is not required for payment, and its overuse inappropriately inflates the frequency of modifier -25.

The Fix: Do not append modifier -25 when it is not necessary. This modifier is linked to minor surgical procedures or those with a global period of 0 or 10 days.

Trying (and Failing) to Help

Occasionally, in efforts to be helpful, staff members will make claim submission choices that are not in the best interests of the practice, such as those in the following examples.

Example No. 6: CPT Code 92250 vs. Code 92134

The physician orders CPT codes 92250 Fundus photography and 92134 Retina OCT with each injection. The coding staff, recognizing that the two codes are bundled, submits the higher paying test code (92250), which is subject to frequency edits. This results in a request for records for an extended period of time. CPT code 92134 is payable monthly for active disease.

Example No. 7: Changing CPT Code 92014 to Code 99214

The retina physician’s documentation supports an established patient visit (Eye visit code 92014) for a comprehensive examination. The coding staff inappropriately changes the code to the established patient E/M services, level four (99214). The high volume of code 99214 triggers an audit.

Documentation requirements are not equal between the two examinations. The chart note is not set up to capture all the documentation needed for the level four E/M service: Review 10 body systems and past family and social history. Had the physician reviewed monthly productivity reports, this error could have been caught and corrected. A protocol should be established so that no one alters any component of the chart note, CPT code, or ICD-10 code without physician approval.

To add insult to injury, the typical Medicare Part B allowable for code 99214 is $110, compared with $130 for code 92014.

Example No. 8: Splitting One Vial of Single-use Drug for a Bilateral Injection

Triamcinolone acetonide injectable suspension 40 mg/mL (Triesence, Alcon) is supplied in a vial labeled for single use. Its labeling states that it is “reimbursed per vial, not per dose (mg),” and that “In order to receive appropriate reimbursement, providers must bill 40 units.”2 Clearly, with 40 units, there is enough drug for both eyes when a bilateral injection is given. Nonetheless, the single dose payment rule is one vial per eye. Incorrect billing will trigger a request for records.

In 2017, CMS mandated the use of modifier -JW for Medicare Part B claims to demonstrate that units were wasted. Here is how this should be coded, duplicated for each eye:

  • Triesence 40 units
  • J3300 4 units
  • J3300-JW 36 units wasted

1. Williams GA. Modifier -25 Under the Microscope. Retina Today. 2017;12(8):21-22.

2. Triesence [package insert]. 2014. Novartis/Alcon.
www.myalcon.com/products/surgical/docs/ars-triesence-fact-sheet-single.pdf. Accessed February 2, 2018.