Audit Issues: VSP Essential Eye Care

VSP's Essential Eye Care (EEC) program allows you to bill VSP for providing medical, as opposed to vision, care. It, naturally, addresses medical problems such as infections, injuries, non-refractive pathologies like glaucoma, corneal degenerations/dystropies, diabetes, etc. There are a number of rules that must be strictly followed, however, or you run the risk of a bad audit outcome. In no particular order, here are special considerations to follow when billing VSP under their EEC program.

Office Visit / Examination Rules

The first rule is that the determination of whether a visit is "medical" and billable under the EEC program, and not a "vision" visit which can only be billed under VSP's routine eye care plans, is entirely based upon the reason for the visit as documented by you in the medical record. If you write that the "Chief Complaint" or "Reason for Visit" is routine, annual, new CL, lost glasses, or any other language that points to the visit being an annual visit, the visit is NOT billable under EEC -- even if you find advanced glaucoma or melanoma. Your findings to not determine if the visit is medical or not -- the reason the patient is coming to you determines that. 

EXPERT TIP: Use the Vision vs. Medical form developed by Dr. Steinberg so patients understand - before - their exam that different rules and coverage apply depending on the nature of the exam, and what circumstances will determine which kind of exam it is. 

Whether the level of service is a level 3, level 4, or level 5 matters. Level 5 visits are uncommon and require that the patient be presenting with a sight-threatening condition that has required considerable testing and time. Most optometric visits will be level 3 or level 4 (99203/99213 or 99204/99214), and most of those will be level 3 visits if the condition is not particularly complex or serious. Allergies, infections, blepharitis, dry eyes, cataracts, subconjunctival heme, and other common anterior segment conditions are going to be level 3 visits. A corneal ulcer in a diabetic patient, however is level 4. Central ulcer with hypopian in a patient with other conditions may be a level 5. 

Even if a visit is "vision" in nature because it was an annual exam, special tests done based on findings during the exam can be performed and billed to EEC. For instance, you find IOP of 26. That would be an indication for fields, OCT, and gonioscopy. Those can be performed that day if you want and billed to EEC. The visit, however, remains a vision exam (92004/92014). 

If you have a patient back another day to do the testing you can only bill for an office visit (i.e., 99213) if your chart reflects that an office visit occurred. This means you need to record the reason for the visit, updated history, meds, acuities, and include an assessment and plan. 

You can NEVER, NEVER, bill for both a 99 and a 92 visit on the same day. And if you bill on consecutive days that is a red flag for an audit. It does not mean you can't, but you need to be sure the patient was actually there on the two consecutive days ("Ms. Jones, let's have you back tomorrow to do the visual fields when there is more time available.")

In all cases, your DIAGNOSIS must be supported by clinical findings from the exam. If your diagnosis is allergy your chart should show anterior segment signs consistent with allergy (injection, papilla, etc.). If your diagnosis is Fuch's Dystrophy, your slit lamp exam needs to reflect endothelial guttata or other abnormal findings consistent with Fuch's. If your electronic record says the cornea and conjunctiva are clear, quiet, and white and you diagnose a pinguecula or pterygium, your exam is going to be rejected on an audit review because there are no clinical findings supporting the diagnosis.  

Special Tests

VSP covers a variety of special tests under their EEC plan. These tests largely follow the same rules as Medicare and medical insurance generally. The single most important thing is that your clinical findings support the reason for the test, showing that there is "medical necessity" to perform the test. 

Medical Necessity means the test will help you in the diagnosis or management of the condition. Tests are not covered when done merely to document the existence of the condition. But helping you follow change over time (as in a nevus, or c/d, or pterygium) supports medical necessity. 

EXPERT TIP: "Medical Necessity" is a threshold requirement for all testing and procedures, not just with VSP, but with all medical plans and Medicare. If a condition is self-limiting, unless the test is needed to aid in making a diagnosis, the test will not be found to be medically necessary. For instance, you cannot take an anterior segment photo of a subconjunctival heme. But you can of a pterygium because the photo will aid in monitoring its growth over time. 

Many tests require an "interpretation and report" along with the test (see chart below). If required, payment will be denied without that interpretation and report being in your records. The I&R should be labeled so it is easily identified and it should reflect why the test was done, what the findings were, and what the management going forward will be based on those findings. If the test has been done before it should reflect a comparison (i.e., "nevus size unchanged from 6 months prior"). 

Covered Supplemental Tests under the EEC Program

Here is a list of special tests VSP will cover in the correct circumstances. 

Audit Triggers and Risks

The primary trigger of EEC audits is high utilization of the program. If you are billing VSP through the EEC program at a higher rate than is common or expected there is a good chance VSP will take notice and will want to determine if you are converting "routine" visits into EEC claims. In particular, if your visits result in the dispensing of glasses or contact lenses and not medical management or treatment of a medical condition VSP will view these claims with suspicion and will carefully examine the reason for the visit, the chief complaint, the services performed, the assessment and the plan to determine if this is actually a routine vision exam and not a medical EEC visit. To the extent that VSP's auditor determine your audited EEC records should have been billed as a vision exam under their routine vision care plan they will retroactively deny all EEC claims for the past year at the same rate the audit identified you were misbilling. In other words, if 60% of the records audited are determined to have been routine and not EEC claims they will order that you repay 60% of what you were paid over the past year for EEC claims. 

Of course the audit will also examine all additional testing performed and billed via the EEC program to determine if it was medically necessary, properly documented, supported by clinical findings, and that there is an interpretation and report when required. Again, if they find that 30% were not properly performed they will retroactively deny 30% of those claims for the past year. 

IMPORTANT EXPERT TIP: When billing VSP using the EEC program, be certain that you have documented a medical reason for the visit, that your chart reflects an assessment and plan related to that medical reason, and that you have clinical findings pertinent to that complaint. For instance, if the presenting complaint was "flashes and floaters x 3d", you will want to be sure you did a dilated fundus exam, that your assessment and plan discuss the findings ("no evidence of retinal tear or detachment noted") and follow-up, and that your diagnosis reflects something other than myopia, etc. (vitreous degeneration, for instance).