Medicare Billing Solutions for Cataract Post-Op Co-Management
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Struggling with Medicare billing for cataract post-op co-management services? Faced with shrinking cash flow, rising Medicare denials, and aged claims beyond 90 days?
Every year, an average of 4 million cataract surgeries are performed by ophthalmologists and postoperative care is often co-managed with referring optometrists. More than 50% of all Americans will have cataracts by the time they are 80 years old, reports Prevent Blindness.
Reduce claim denials and boost your Medicare revenue with our cataract post-op co-management tips.
Cataract Post-Op Co-Management Claim Case Challenge
Fast Pay Health optometric billing consultants process hundreds of Medicare claims every week. Let’s look at a challenge, solution, and outcome that we put into action for a two-doctor, one-location Texas-based optometry practice struggling with denied Medicare claims for cataract post-op co-management services.
Challenge
The date the patient visited the optometrist was often confused with the surgery date.
The office billers were not using the correct Assumed Care Date (the date postoperative care was assumed by another provider) and Relinquished Care Date (the date the provider stopped postoperative care).
The surgeon’s name and NPI were not listed on the claim as the referring physician.
Since the cataract post-op care was performed within the global period of the first postoperative claim, the office billers were not appending the correct modifier on the second postoperative claim to ensure both claims were paid correctly.
The surgeon’s medical claim should have been filed to Medicare before the optometrist filed the postoperative claim.
The claim was billed with 89 units instead of 1 unit for Medicare, which led to Medicare denying the claims.
ROI Outcome
Within two months of this two-doctor practice signing up with Fast Pay Health for optometric billing services, Medicare paid more than 96% of the refiled denied claims, and the practice collected more than $26,000.
The key financial metric to focus on is ensuring claims are “clean and free from errors” before you submit them. Knowing how to prevent rejections or denials in the first place is your best return on investment (ROI).
Outsourcing optometry billing services allows you to delegate these tasks to a professional team specializing in the nuances of the financial twists and turns related to eye care.
Cataract Post-Op Co-Management Pro Tips
Use Modifier 55 to identify when one doctor performs the postoperative management and another doctor performs the surgical care–only procedure (Modifier 54). See our blog, How (and How Not) to Use Common Medical Billing Modifiers, for red flags to look out for when billing with a few common modifiers.
Remember, if the surgeon has not filed their claim or filed without using the correct modifier indicating surgical care only, your co-management claim will be denied. Maintaining good communication with the surgeon's office is important to avoid delayed payments.
If you provide postoperative care for a patient who had cataract surgery in both eyes, also use Modifier 79 when you code the second eye. When you use Modifier 79 correctly, this allows the claim for the second eye to be paid. Otherwise, your claim will be denied as a duplicate procedure. It’s not uncommon for postoperative claims to be paid incorrectly or not at all—especially when the surgery of a second eye occurs during the global period for the surgery performed on the first eye. Remember, each eye’s global period (postoperative) runs independently.
To ensure you correctly code eye care Medicare claims, always check with the Medicare Administrator Contractors (MAC) in your area. Depending on your state, some insurance carriers may require 1 unit or the number of days you provide co-management services.
Box 19 on the CMS 1500 02/12 is MAC-dependent and identifies additional information about the patient’s condition or the claim.
While it depends on the state, most of the time, the surgeon should be entered as the referring physician in Box 17 with the NPI in Box 17b on the claim.
A global period consists of the time before, during, and after a surgical period that covers the patient's care for a particular procedure.
Cataract Co-Management and Transfer of Care Compliance
The U.S. Department of Health and Human Services OIG (Office of Inspector General) is cracking down on co-management compliance. You must manage the patient’s transfer of care correctly and ensure that it is medically acceptable.
Make sure you have a separate written transfer agreement for every patient. The surgeon and co-managing optometrist must keep a signed copy of the transfer agreement in the patient’s medical record. And do not determine (standing orders) what post-op care the patient needs before the cataract surgery.
If you suspect that Medicare or commercial non-Medicare plans may not cover the service or test you will provide to the patient—and the patient may be responsible for out-of-pocket costs—obtain an Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-31.
The ABN must be completed and signed by the patient BEFORE providing services or items not covered by insurance. Do not continue the procedure until the patient signs an ABN and accepts financial responsibility for non-covered services. Always keep the signed ABN in the patient’s medical records. The ABN is invalid for any contractually obligated write-off.
Experience Positive ROI with a Full-Service Optometric Billing Partner
These cataract post-op co-management guidelines are a great place to start on your path to healthier cash flow and fewer denials. The next step is finding a long-term optometric billing solutions partner to streamline your insurance claim process.
Ready to experience the positive ROI of outsourcing eye care billing? Fast Pay Health optometric billing consultants will help you get started. Request a free practice analysis today—we’re just a form submission away.
