decisionhealth Newsletters, Part B News - 2015 Issue 9 (September)
OIG eyes questionable ophthalmology billing, suggests where payers look for trouble
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Article Overview
This article covers an OIG report on questionable billing patterns in ophthalmology, with emphasis on utilization trends tied to cataract surgery, wet age-related macular degeneration services, diagnostic testing, and selected claim modifiers. It is relevant to ophthalmologists, optometrists, coders, compliance teams, auditors, and payer integrity staff who monitor high-volume service patterns and billing review flags. The article also notes the involvement of CMS and the American Academy of Ophthalmology in developing the measures and the agency response to the report.
Why This Topic Matters
The report highlights utilization patterns that may draw payer scrutiny and affect audit, compliance, and reimbursement review in ophthalmology practices.
Article Sections
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Overview of the OIG report
Introduces the report’s focus on ophthalmology billing patterns and the general areas of concern it identifies.
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Measures related to wet AMD treatment
Summarizes service-utilization measures associated with treatment patterns for wet age-related macular degeneration and related billing review areas.
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Complex cataract surgery billing
Describes the report’s attention to cataract surgery utilization patterns and the related category of provider billing review.
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Testing and imaging for wet AMD
Covers diagnostic service utilization measures linked to wet AMD evaluation and monitoring.
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Claims using modifiers
Addresses the report’s review of claim patterns involving selected modifiers and the compliance concerns they may raise.
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CMS response
Summarizes CMS’s general response to the report and its stated interest in reviewing identified billing patterns.
What You Will Learn
- How an OIG report frames ophthalmology billing review concerns
- Which broad service categories were examined for utilization patterns
- What types of claim-level patterns may attract payer scrutiny
- How CMS responded to the report’s findings
Who Should Read This
- Ophthalmologists
- Optometrists
- Medical coders
- Compliance officers
- Billing staff
- Payer auditors
- Revenue integrity teams
Codes Discussed
Modifiers Discussed
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