Coding and Billing

The Coding Protocol Mistake with Huge Repercussions

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Oct. 6, 2021

It’s easy to let coding software or a staff member code patient visits on your behalf. However, it’s essential that the doctor closely review all coding that is submitted. Here’s why, and what can happen when the doctor does not double-check coding.

For a doctor to become a provider for a third party (eg: Medicare, Medicaid, VSP, EyeMed), the doctor must sign an agreement attesting that accurate claims will be submitted.

It is permitted that billing specialists or even alternate sources, such as software, may help select the codes used, however, the provider must ensure that the submitted claim accurately reflects the services provided using appropriate coding. The doctor is ultimately responsible for the codes submitted to a third party for billing purposes.

Let’s say that another way. In the case of inaccurate claims, it is the provider who will be fined and/or jailed. We hear employee optometrists often say, “But I’m just an employee optometrist doing what I’m told.” Well, then consider this case that really happened. An optometrist was hired as an employee to see patients. The employee optometrist would see patients, then turn them over to the optician in the practice who completed everything needed, including coding and billing for the examination. The doctor never checked to see if the coding submitted was supported by the patient record documentation.

Medicare audited the doctor’s patient records and reported to the optometrist that the coding and billing was not supported by the patient record documentation, so the optometrist owed Medicare over $300,000 back in over-payments plus there would be additional penalties placed on the optometrist. The optometrist’s defense was “I didn’t know.” Medicare’s response was, “If you accept money from the federal government, then it is your responsibility to know.” This did not end well for the optometrist.

So, the question we are asking today is: “Do you check the coding of each patient’s record that you see to make sure, not only that the coding is supported by your documentation, but that the coding is appropriate?” Keep in mind, when you sign the record, you are stating that everything in that record, including the coding, is accurate and true. If you are signing patient records without checking the coding, then you are at risk both legally and financially for what someone else may put into that record.

That’s not a safe place to be.

If you are a student at a school or college of optometry where the coding education is not emphasized or taught well, then ask your practice management educator for access to the free coding course that has been placed within the Association of Practice Management Educators (APME) website. (This course is only available at no charge to optometry students while they are in optometry school.)

If you are a practicing doctor, then every major educational seminar across the country hosts coding courses. Coding courses are also offered online. Medicare has the CMS Medicare Learning Network. In other words, there are many coding resources available. Each year, there are changes to coding. It is your responsibility to keep up with the changes. You should spend 2-3 hours of your continuing education each year on coding courses.

It’s your responsibility to see that your patient record is accurate, including the coding. You signed a legal document with every third party for which you are a provider saying that you accept that responsibility. There’s no excuse for not meeting that agreement.

If you want to know more about the penalties that Medicare can impose, then read THIS document.

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