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Dr. Nguyen Had Inadequate Documentation to Support Approximately $27,255 in Vision Care Services

Audit found that optometrist did not document all necessary information to support services billed under certain procedure codes.

Table of Contents

Overview

Dr. Nguyen did not have the required documentation to substantiate the vision care services he billed using evaluation and management (E/M) service codes 99337 and 99328. Dr. Nguyen billed under these codes only when providing services to youths residing in DYS facilities and DCF programs. He billed under procedure code 99337 in 1,844 instances, totaling $86,535, and under procedure code 99328 in 2,523 instances, totaling $170,167. Out of the 180 statistically sampled claims we tested, 39 were billed by Dr. Nguyen using the 99337 or 99328 code, but for those 39 claims, Dr. Nguyen did not document a comprehensive medical history or a comprehensive examination as required.

Further, DYS and DCF officials at the facilities where these services were provided told us that, based on their observations, Dr. Nguyen only provided routine (not complex) annual eye exams and appointments were scheduled weeks in advance. They also stated that when Dr. Nguyen visited their facilities, his exams typically lasted only 20 to 30 minutes, in contrast to the 60 or 75 minutes that medical professionals typically spend on exams billed using the 99337 and 99328 codes. For all serious or emergency eye problems, they told us, youths were transported to the hospital for vision care.

Because Dr. Nguyen did not adequately document all the necessary information to support billing for vision care using procedure codes 99337 and 99328, there is inadequate assurance that the services met the requirements for using these codes.

Authoritative Guidance

Regarding billing using procedure code 99328, 101 CMR 315.000 provides the following description of the related services:

Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. . . . Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver.

Regarding billing using procedure code 99337, 101 CMR 315.000 provides the following description of the related services:

Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive interval history; a comprehensive examination; medical decision making of moderate to high complexity. . . . Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver.

These documentation requirements for procedure codes 99328 and 99337 are the same ones described in the American Medical Association’s Current Procedural Terminology Professional Edition 2017.

Reasons for Insufficient Documentation

Dr. Nguyen stated that he believes that he has adequate documentation to support the vision care services he billed MassHealth for using the 99328 and 99337 E/M codes.

Recommendations

  1. Dr. Nguyen should ensure that he properly documents the comprehensive medical history and comprehensive examination involved for each instance in which he uses E/M code 99328 or 99337.
  2. Dr. Nguyen should collaborate with MassHealth to determine the amount to be repaid for improperly documented E/M services.

Auditee’s Response

Regarding billing 99328 and 99337, Masshealth only allowed us to bill only these codes. [Manager @ Masshealth: “Similarly, 99337 (high complexity) is the appropriate replacement for the deleted 99333. Optometrists have only been allowed to bill for 99323 and 99333 from this particular series of E/M's—therefore, they are now only allowed to bill for those two replacement codes 99328 and 99337. We do not allow them the lower-level codes.”] These outdated codes were established decades ago without considering the change of technology. We had technology like the retinal camera that allows us to image the retina in 2 seconds or autorefractor that determined the eyeglasses prescription in 5 seconds. If 90 minutes was required to do an eye examination, the reimbursement rate $40 would be less than a technician we would hire in the office not calculating the cost of technology investment and our cost of traveling to and from these 38 facilities. These locations ranged from Greenfield to Brewster, MA. Regarding the complexity of the medical exam, the auditors only interviewed [10] out of 38 facilities, therefore it would be hard to generalize the complexity and time spent. However, from the [180] charts audited out of [12,887] encountered billed, more than half were high complexity cases ranging from corneal puncture with a pencil to Idiopathic Intracranial Hypertension. All these encounters were upon the requests from the medical staffs at these facilities and the majority of the cases were comprehensive eye examination.

MassHealth’s Response

  1. MassHealth agrees that Dr. Nguyen should properly document the comprehensive medical history and comprehensive examination involved for each instance in which he bills MassHealth using E/M code 99328 or 99337.
  2. MassHealth will outreach to the provider to identify paid claims for evaluation and management services for which the provider did not maintain sufficient documentation, including documentation that the provider performed a comprehensive medical history and a comprehensive examination. MassHealth will determine the overpayment amount and initiate recovery from Dr. Nguyen after the final audit report has been issued.

Auditor’s Reply

Dr. Nguyen states that MassHealth instructed him to use procedure codes 99328 and 99337 when billing for eye exams provided outside the office. However, in its response, MassHealth does not support this assertion; it states that it will determine when overpayments occurred and will seek reimbursement. Further, regardless of what technology is used during an exam, providers are required to adequately document all the necessary information to support billing for vision care using procedure codes 99337 and 99328. In the case of the billings in question, there is inadequate documentation to substantiate that the services billed met the requirements for using these procedure codes.

 

Date published: July 16, 2018
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