Ophthalmology Services: Questionable Billing and Improper Payments per Medicare

The Office of the Inspector General (OIG) reports that Medicare is vulnerable to fraud, waste, and abuse for wet Age-related Macular Degeneration (wet AMD) and cataracts:

• Administration of Lucentis injections for wet AMD more than once every 28 days (based on local coverage determinations)
• Billing for a second cataract surgery on the same eye
• Submitting disproportionately more claims for complex than standard cataract surgery

Review the following resources for proper claims coding, billing, and payment:

• Questionable Billing for Medicare Ophthalmology Services OIG Report, September 2015
• Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims OIG Report, December 2014
• Cataract Removal, Part B MLN Matters® Special Edition Article
• Implementation of CMS Ruling Regarding Presbyopia-Correcting Intraocular Lenses for Medicare Beneficiaries MLN Matters Article
• Multiple Procedure Payment Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures MLN Matters Article
• Medicare Vision Services Fact Sheet
• NCCI Policy Manual for Medicare Services, Chapter 8: Section D: Ophthalmology
• Medicare National Coverage Determinations Manual, Part 1: Section 10.1: Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery
• Medicare Benefit Policy Manual, Chapter 15: Section 120: Prosthetic Devices and Section 260.2: Ambulatory Surgical Center Services