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Overview of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Frederick Wagner Jr.

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Frederick Wagner Jr.

Table of Contents

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services for approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2017, MassHealth paid healthcare providers more than $15 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.

According to Section 402 of Title 130 of the Code of Massachusetts Regulations, MassHealth pays for vision care provided to eligible MassHealth members. Dr. Wagner is an optometrist and sole business proprietor who lists his home as his office. He is a certified MassHealth provider who travels to nursing facilities across the state. Dr. Wagner received a total of $1,045,556 for vision care provided to MassHealth members during the audit period, as detailed below.

MassHealth Payments Received by Dr. Wagner

Calendar Year

Number of Members Served

Number of Claims

MassHealth Payments

2014

1,777

9,303

$250,634

2015

1,755

9,086

244,004

2016

1,873

9,510

292,392

2017

1,755

7,486

258,526

Total

7,160*

35,385

$1,045,556

*     The unduplicated total number of members served is 3,741.

Vision Care

The vision care provided by opticians, optometrists, and ophthalmologists1 to eligible MassHealth members includes performing eye exams; diagnosing, treating, and managing disorders of the eye and the associated structures; and fitting and ordering eyewear. MassHealth instructs providers to use specific procedure codes to bill for vision care services, such as dispensing services, eyeglass repairs, comprehensive eye services, intermediate services, consultations, and problem-specific eye examinations.

Dispensing services: The following are considered dispensing services: assisting a member in choosing appropriate frames, taking necessary measurements for ordering lenses and frames from the optical supplier, fitting the completed eyeglasses to the member, determining whether the member can see clearly through the eyeglasses, making necessary adjustments to the lenses and/or frames, and giving the member the eyeglasses. Dispensing also includes periodic readjustments and minor repairs of eyeglasses for the first six months from the date the member receives them.

Repairs: Members are entitled to have their broken eyeglasses repaired with replacement parts from the optical supplier. If the replacement parts are not available from the optical supplier, members are entitled to entire replacement frames.

Eye examinations: Each member is entitled to an eye examination once per 12-month period if they are under the age of 21 and once per 24-month period if they are 21 or older.

Eye Examination Procedure Codes

Procedure Code

Description

92002

Intermediate eye exam, new patient

92004

Comprehensive eye exam, new patient

92012

Intermediate eye exam, established patient

92014

Comprehensive eye exam, established patient

 

Comprehensive services: These services include patient history documentation, general medical observation, external and ophthalmoscopic2 examination, gross visual field evaluation, and basic sensorimotor3 examination. The services always include the diagnosis and treatment of a new problem related to possible disease of the visual system, such as glaucoma, cataracts, or retinal disease. This level of service represents the most complex and thorough service of the entire visual system.

Intermediate services: These services include patient history documentation, general medical observation, external examination of the eyes and the accessory structures attached to the eyes, and other diagnostic procedures as indicated. An example of this is an established patient with a known cataract not requiring comprehensive ophthalmological services, because the patient has already been diagnosed, but requiring a review of the visual system. This level of service is the least complex and is related to existing conditions or new diagnoses that may not be related to the original diagnosis.

Consultation: Before a provider dispenses eyeglasses to a MassHealth member living in a nursing facility, facility staff members and the dispensing optometrist or ophthalmologist must, in consultation, agree that the member would benefit from eyeglasses. This consultation must be documented in the member’s medical record. In addition, a consultation should document the member’s complaints and symptoms; the condition of the eye; and, if available, the name of the person who referred the member for eyeglasses.

Problem-specific eye examinations: A member is entitled to an eye examination more than once per eligibility period when there is a referral from his/her physician or when his/her medical record documents a condition or chronic disease such as blurred vision, headaches, pain, redness, infection, diabetes, hyperthyroidism, human immunodeficiency virus, or cataracts.

Massachusetts Correctional Industries

MassHealth’s optical supplier is Massachusetts Correctional Industries (MassCor). For eligible Medicaid members, optometrists and opticians use MassCor’s online system to order eyeglass-related materials and services produced or provided by Massachusetts inmates, including eyeglass frames, eyeglass lenses, frame cases, lens tints and coatings, and replacement parts.

Vision Care Billing and Documentation Requirements for Evaluation and Management Procedure Codes

During the audit period, MassHealth paid Dr. Wagner for 12,005 vision care services that he billed using medical service evaluation and management (E/M) procedure codes for members living in nursing facilities. Based on the American Medical Association’s Current Procedural Terminology Professional Edition 2014 (the CPT Codebook), E/M services are divided into broad categories such as office visits, hospital visits, and nursing facility visits. Most categories are divided into two or more subcategories. For example, for office visits, there are subcategories for new patients and established patients. These subcategories are further classified into levels of E/M services, broken down by the nature of the work, the place of service, and the patient status. The more complex the service, the more the physician is compensated; therefore, for complex services, more information must be documented. Medical providers must select the E/M procedure code that best represents the services rendered and ensure that the medical documentation for those services meets the requirements in the CPT Codebook.

During our audit period, Dr. Wagner billed the following E/M procedure codes more frequently than other E/M codes for vision care provided to MassHealth members living in nursing facilities.

Top E/M Codes Billed by Dr. Wagner

Procedure Code

Description in CPT Codebook

99305

Nursing facility visit for E/M for a new patient, which requires these three key components:

  • a comprehensive history
  • a comprehensive examination
  • medical decision-making of moderate complexity

Typically, 35 minutes are spent at the bedside and on the patient’s facility floor.

99306

Nursing facility visit for E/M for a new patient, which requires these three key components:

  • a comprehensive history
  • a comprehensive examination
  • medical decision-making of high complexity

Typically, 45 minutes are spent at the bedside and on the patient’s facility floor.

99309

Nursing facility visit for E/M for an established patient, which requires at least two of these three key components:

  • a detailed interval history
  • a detailed examination
  • medical decision-making of moderate complexity

Typically, 25 minutes are spent at the bedside and on the patient’s facility floor.

 

When Dr. Wagner bills for medical services using certain E/M codes (the three shown above, as well as codes 99304, 99308, and 99310), he must ensure that his medical documentation of services rendered includes the following key components for comprehensive services:

Comprehensive History

 

Comprehensive Examination

 

High-Complexity Decision-Making

  • Chief complaint
  • Extended history of present illness
  • Complete review of systems performed
  • Complete past, family, and/or social history

 

  • Examination of all nine organs/systems
  • Examination of every element of one organ or system

 

 

  • Extensive number of diagnoses or management options
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of significant complications, morbidity, and/or mortality

1.    Opticians specialize in filling lens prescriptions, helping patients choose eyeglasses, and fitting eyeglasses. Optometrists perform vision examinations, fit and prescribe contact lenses and eyeglasses, diagnose and treat eye-related conditions, and prescribe some medications. Ophthalmologists can perform all the same services as optometrists as well as eye-related surgeries.

2.    This routine examination of the back of the eye is conducted to check for disease or other eye problems.

3.    This examination evaluates the range of motion of the eyes to determine whether they move together.

Date published: September 24, 2019
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