A Sharper View of Evolving Optometry Specialty Emerging Schemes
Over recent months, Codoxo’s partners have observed an unusual procedure being performed by the Optometry Specialty that warrants monitoring. The procedure, CPT (Current Procedural Terminology) code, 65778, is the application of amniotic membrane placed directly on the ocular surface without suturing, much like a contact lens. The amniotic membrane comes either cryopreserved or dehydrated which is prepared from placentas obtained following a cesarian section. The procedure may be performed by either an Optometrist or Ophthalmologist depending on what plan policy allows. The HCPCS code for the membrane itself is V2790 which was not observed as billed in association with the 65778.
Per CMS guidelines, the indications for use for amniotic membrane include acute chemical burns, corneal scars, or defects, to cover glaucoma drainage, keratitis, keratoconjunctivitis, and ocular herpes. Please review your plan policy for coverage and other limitations.
Things to monitor:
- The frequency at which the provider is performing this procedure per patient. The initial lead that prompted this review included a patient who had this procedure performed more than 30 times.
- Use of the 79 modifier is not appropriate in this situation if it is applied to both eyes, especially if performed by an optometrist since they are not allowed to perform surgical procedures.
- Separate billing for use of 69990, operating microscope
How to focus on high-risk providers using Codoxo’s Fraud Scope Schemes module:
- Select Schemes [Professional, Rendering, Sort by Total Paid Exposure]
- Top Specialties widget – Type ‘OPHTH’ in the search bar and click Search
- Highlight the row for Ophthalmology and click Codes
- Click the drop-down menu for the Code column, type 65778, and click Apply
- Check the box for 65778, which opens 3 view options [Providers, Patients, Reasons]
- Click Providers to view the providers with the highest total paid exposure for 65778
- After choosing a provider to evaluate further, click View Reasons in the Actions column to review the AI detector reasons
- Focus on detectors identifying high claim volumes or changes in billing behavior, such as Suspicious Trends, Time Behavior or Frequent Combinations
- Review the deterministic reasons to get a complete picture of the practice patterns and potential overpayments
- Repeat this process for the specialty Optometry and for HCPCS code V2790
Some health plans prohibit Optometrists from performing this procedure or the procedure code contains bundled payment for the membrane and the procedure. Please review and verify the policies and coverage requirements for your health plan.
Under the microscope with Codoxo’s Query Aggregates
- Select Query, Query Builder [Professional, Aggregates, Rendering, Procedure]
- If you would like to review all providers in all peer groups, continue to step 4
- If you prefer to review only Ophthalmologists and Optometrists, choose those specialties from the Rendering Specialties menu
- Click Procedure Code from the filters, choose These as the operator, and input 65778 and V2790
- Click Search
This search will enable you to review providers with the highest overall payments and highest paid per-patient values.
Sharpen your view of coding errors/policy violations using Codoxo’s Query Claims
- Select Query, Query Builder [Professional, Claims]
- Click Procedure Code from the filters, choose Exact as the operator, and input V2790
- Client Provider Payment Received, Minimum $1
- Click Search
The results will include only paid claims where V2790 was the only procedure billed.
- Center for Medicare and Medicaid Services (CMS.gov) Local Coverage Determination (LCD) https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57679&ver=4
- Modern Optometry Article
- AMA (American Medical Association) Article on Scope of Practice Creep by Optometrist in California
- American Medical Association version of the 2022 CPT coding manual, page 501.
If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via email@example.com.