Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Q B
U ESTIONABLE  ILLING FOR 
 
M O
EDICARE  PHTHALMOLOGY 
 
 
S  
ERVICES 
 
 
   
 
 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2015 
OEI-04-12-00280   
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICARE 
OPHTHALMOLOGY SERVICES  
OEI-04-12-00280 
     
WHY WE DID THIS STUDY 
 
In 2012, Medicare paid $6.7 billion to 44,960 providers for ophthalmology services that 
screen for, diagnose, evaluate, or treat two prominent eye conditions:  wet age-related 
macular degeneration (wet AMD) and cataracts.  Since 2010, the Office of Inspector 
General has investigated over 100 providers of ophthalmology services for fraud.  We did 
this study to determine the extent to which ophthalmology services are vulnerable to 
fraud, waste, and/or abuse. 
   
HOW WE DID THIS STUDY  
 
We developed measures of questionable billing and used them to identify several 
different types of possible fraud, waste, and abuse.  We examined approximately 
34 million paid claims for ophthalmology services from 2012.  We identified providers 
with unusually high billing for procedures that screen for, diagnose, evaluate, or treat 
wet AMD or cataracts. For providers with questionable billing, we calculated the dollar 
amount that Medicare paid for services associated with these measures.  We also 
identified the metropolitan areas in which providers with questionable billing were 
located and the medical specialties of providers billing for ophthalmology services.   
 
WHAT WE FOUND 
 
While most providers did not demonstrate questionable billing on any of our measures in 
2012, 4 percent of providers billing Medicare for ophthalmology services demonstrated at 
least one of our nine measures of questionable billing.  Overall, Medicare paid these 
1,726 providers $768 million for ophthalmology services in 2012, of which $171 million 
was for services associated with the measures on which these providers demonstrated  
questionable billing. In seven metropolitan areas, the percentage of Medicare payments 
associated with our measures was at least twice as high as it was nationally.  Medicare 
also paid $2 million for ophthalmology services to 821 providers that were not listed as 
eye care specialists in the Centers for Medicare & Medicaid Services (CMS) databases.      
       
WHAT WE RECOMMEND  
 
There may be legitimate reasons why some of the providers demonstrated questionable 
billing on the measures in this report.  However, providers with questionable billing 
warrant further scrutiny. Therefore, we recommend that the CMS (1) increase 
monitoring of billing for ophthalmology services, including using measures of 
questionable billing similar to those used in this review and (2) review and take 
appropriate action regarding providers with questionable billing identified by this 
evaluation and conveyed by a separate memo.  CMS concurred with both of our 
recommendations. 
   
TABLE OF CONTENTS 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................6 

Four percent of providers billing for ophthalmology services in 

2012 demonstrated questionable billing on at least one of our 

measures; Medicare paid them $171 million for services related to 

these measures .................................................................................6 

In seven metropolitan areas, the percentage of Medicare payments 

associated with our measures of questionable billing was at least 

twice as high as it was nationally...................................................10 

Medicare paid $2 million for ophthalmology services to 

821 providers that were not listed as eye specialists in CMS 

databases ........................................................................................11 
 
Conclusion and Recommendations ............................................................12 

Agency Comments and OIG Response..........................................14 

Appendixes ................................................................................................15 

A: Detailed Methodology .............................................................15 

B: Provider Enrollment Data and Claims Processing ...................22 

C: Number of Providers by Number of Measures of Questionable 

Billing for Which Providers Exceeded Thresholds, by Specialty 

Strata, 2012 ....................................................................................23 

D: Providers  With Unusually High Billing by Each Measure of 
 
Questionable Billing, 2012 ............................................................24 

E: Agency Comments  ...................................................................28 

Acknowledgments......................................................................................31 

 
 
 
 
 
 
   
   
OBJECTIVE 
To identify and describe providers with questionable billing for 
ophthalmology services in 2012. 
BACKGROUND 
Ophthalmology services are those in which providers screen for, diagnose, 
evaluate, or treat conditions associated with the eye.  Medicare Part B 
covers such services provided by licensed specialists, including 
ophthalmologists and optometrists.1  Since 2010, the Office of Inspector 
General (OIG) has investigated over 100 providers of ophthalmology 
services for fraud. We did this study to determine the extent to which 
ophthalmology services are vulnerable to fraud, waste, and/or abuse.   
Medicare Requirements for Ophthalmology Services  
Medicare Part B covers ophthalmology services that are reasonable and 
necessary for the diagnosis or treatment of an individuals condition.2   
Medicare uses a combination of national and local requirements to 
determine whether certain ophthalmology services are covered.  National 
requirements are created at the Federal level and apply to all Medicare 
beneficiaries and claims processing contractors.3  In the absence of 
specific national requirements, claims processing contractors may create 
their own local coverage determinations (LCDs), which are contractor 
decisions about whether to cover particular services in their respective 
jurisdictions.4    
Medicare covers ophthalmology procedures for many eye conditions.  
However, the two eye conditions for which Medicare pays the most each 
year are wet age-related macular degeneration (wet AMD) and cataracts.  
In 2012, Medicare paid 44,960 providers $6.7 billion for ophthalmology 
services for these two conditions.5  
Wet AMD. Medicare paid $2.2 billion to providers in 2012 for services 
that screen, diagnose, evaluate, or treat wet AMD.6   This disease is the 
leading cause of severe vision loss in people over age 65 in the United 
States. 
____________________________________________________________ 
1 Social Security Act,   1832(a)(1); the Centers for Medicare & Medicaid Services 

(CMS),  Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15  30.4. 
 
2 Social Security Act,  1862(a)(1)(A). 
 
3 Social Security Act,  1862(a)(1)(A), 1862(l), 1869(f)(1)(B); CMS, Medicare National 

Coverage Determinations  Manual, Pub.  No. 100-03, Foreword. 

4 Social Security Act,  1862(a)(1)(A), 1862(l), 1869(f)(2)(B); CMS, Medicare 
 
Program Integrity Manual, Pub. No. 100-08, ch.13,  13.1.3. 

5 OIG analysis of 2012 National Claims History (NCH) Part B file, 2014. 

6 OIG analysis of 2012 NCH  Part B file, 2014. 

Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  1 
     
   
Medicare covers several services, including fluorescein angiographies, to 
diagnose or evaluate wet AMD, but Medicare does not have any national 
requirements that place specific limits on these services.  However, some  
claims processing contractors have LCDs limiting the number of these 
diagnostic or evaluation services that a provider may bill per eye 
annually.7    
Additionally, Medicare covers several services to treat wet AMD, 
including laser surgery, biologic injections, and the administration of 
drugs. In limited circumstances, laser surgery can be the most appropriate 
treatment for wet AMD.  In even fewer circumstances, physicians treat 
wet AMD with laser surgeries and concurrent biologic injections or drug 
administration.8    
One of the biologics most commonly used to treat wet AMD is Lucentis, 
for which Medicare paid an average of $2,013 per injection in 2012.9   
Medicare does not have a national requirement limiting the frequency at 
which a provider may bill for this injection; however, six claims  
processing contractors had LCDs in 2012 specifying that Lucentis 
injections are not covered more frequently than every 28 days per eye.  To  
support the monthly limit on Lucentis injections, these LCDs cite the 
FDA-approved dosing guidelines on the biologics label.  These guidelines 
state that injections should be administered between once every 28 days 
and once every 3 months.10     
Cataracts. Medicare paid $3.5 billion in 2012 for services that screen for,  
diagnose, evaluate, or treat cataracts, the leading cause of blindness in the 
world.11   A cataract is a clumping of protein in an eyes lens that causes the 
lens to become cloudy.   
____________________________________________________________ 
7 For example, L27584 (retired) stated that fluorescein angiographies are considered  
medically necessary no more than nine times per eye annually, so claims that exceed this 
frequency will be suspended and reviewed  for medical necessity.  CMS, Local Coverage  
Determination (LCD) for Ophthalmic Angiography (Fluorescein and  Indocyanine Green)  
(L27584), Palmetto GBA.   Under these requirements, additional exams are denied as  not  
reasonable and necessary unless the medical need for the additional exams is fully 
documented. 
8 Kent, Christopher, Macular Degeneration:   Is Laser Still Relevant?, Review of 
Ophthalmology, August 13, 2009. 

9 The Food and  Drug Administration (FDA) approved Lucentis to treat wet AMD in 
 
2006. 

10 FDA,  Lucentis  (ranibizumab injection) Intravitreal Injection, Initial US Approval:  

2006.  US BLA (BL125156) Ranibizumab Injection.  For example, CMS, Local 

Coverage Determination (LCD) for Ranibizumab (Lucentis)(L29266), First Coast Service 

Options, Inc, June 14, 2011. 

11 OIG analysis of 2012 NCH  Part B file, 2014; National Institutes of  Health, Leading 

Causes of  Blindness, NIH Medline Plus. Volume 3,  Number 3, Summer 2008. 

Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  2 
     
   
Medicare covers several types of surgeries that treat cataracts by removing 
the cloudy, natural lens in an eye, and replacing it with a synthetic, 
crystalline lens. Medicare pays a higher rate for especially difficult 
cataract surgeries, which are called complex cataract surgeries.  In 2012, 
Medicare paid an average of approximately $900 for each complex 
cataract surgery and $700 for each regular cataract surgery.      
Medicare Global Surgeries and Modifiers 
Most eye surgeries, including cataract removal surgeries, are categorized 
as global surgeries.  A global surgery is a group of clinically related 
services that are coded and billed for as a single unit.12 This includes the 
surgical serviceswhich are invasive procedures that only physicians 
with appropriate training should performand related preoperative and 
postoperative services to evaluate the beneficiary. Medicare pays for these 
services with a single paymentthe global surgery fee.  CMS bases global 
surgery fees on the cost of the surgery and the average number of related 
postoperative services required during the global surgery period.13      
Medicare will sometimes pay separately for preoperative and 
postoperative services that are normally covered under the global surgery 
fee. To do so, Medicare requires certain modifiers on claims.  For 
example, modifiers 24 and 25 indicate that evaluation and management 
(E&M) services on claims submitted during the global surgery period are  
unrelated to the global surgery.  Similarly, modifier 22 indicates that a 
global surgery is particularly complex and will require substantially more 
E&M services than are factored into the cost of the surgery.14    
Previous OIG Work 
OIG has found vulnerabilities in Medicare payments for ophthalmology 
services. For example, in 2009, OIG found that Medicare paid 
approximately $97.6 million in 2005 for E&M services that were included  
in global eye surgery fees but were not provided during the global eye 
surgery period.15   Also, a 2014 report found that Medicare paid $22 million 
____________________________________________________________ 
12 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12    40; CMS 
Medicare Learning  Network,  Global Surgery Fact Sheet (March  2015). 
13 Ibid.  Global surgery periods are the lengths of time in which  related services are 
covered under  the global  surgery fee, and they vary  depending on the severity of the 
surgery.  Global surgeries can  be split into  major surgeries, which  have  a 90-day global 
period, and minor surgeries, which have a global  period of  10 days or  fewer.  
14 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch.  12   40.2.A.7,  
40.2.A.8, and 40.2.A.10. 
 
15 OIG,  Nationwide Review of Evaluation and  Management Services Included in  Eye and 
 
Ocular Adnexa Global Surgery Fees for Calendar Year 2005, A-05-07-00077, 

April 2009. 

Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  3 
     
   
for ophthalmology claims that were potentially inappropriate based on 
national and local coverage requirements.16  
METHODOLOGY 
This evaluation is national in scope and is based primarily on paid 
Medicare Part B claims for 64 different Healthcare Common Procedure 
Coding System (HCPCS) codes for ophthalmology services.17 More 
specifically, our analysis examined approximately 34 million paid claims  
billed by 44,960 unique providers in 2012.  Each Medicare-allowed 
amount is composed of the Medicare Part B responsibility (80 percent) 
and the beneficiarys responsibility (20 percent).18   Throughout this report, 
when we refer to the dollar amount that Medicare paid for each service, 
we are referencing the Medicare-allowed amount for each service.   
For a detailed methodology and a full description of our measures of 
questionable billing for ophthalmology services, refer to Appendix A. 
Identification and Description of Providers With Questionable 
Billing for Ophthalmology Services   
We classified providers into four strata on the basis of the specialty code 
field on their Medicare claims:  ophthalmology, optometry, ambulatory 
surgery, and all other specialties.  We analyzed each specialty group 
separately because we observed differences in their billing patterns.  We  
identified providers as those having unique national provider identifiers 
(NPIs).  
We developed nine measures of questionable billing for ophthalmology 
services to capture several different types of possible fraud, waste, and 
abuse. Our measures of questionable billing are grouped into four 
categories. These categories covered providers with unusually high billing 
for (1) procedures to treat wet AMD, (2) complex cataract surgeries, 
(3) tests to diagnose wet AMD, and (4) ophthalmology claims using 
modifiers. The FDA approved label for Lucentis was the basis for two 
measures of questionable billing, both of which were in the first 
categoryunusually high billing for procedures to treat wet AMD.  We  
developed the remaining seven measures on the basis of past OIG work 
and fraud investigations related to ophthalmology services, as well as 
input from staff at CMS and the American Academy of Ophthalmology. 
____________________________________________________________ 
16 OIG,  Medicare Paid  $22 Million in 2012 for Potentially Inappropriate Ophthalmology 
 
Claims, OEI-04-12-00281, December, 2014. 

17 Medicare Part B services are  classified and paid for using HCPCS codes. 
 
18 Medicare Part  B also required a deductible  of  $99.90  per month in 2012.
  
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  4 
     
   
When analyzing each measure of questionable billing, we excluded claims  
processed by contractors that had any LCDs pertaining to the HCPCS 
code(s) covered by the measure.  Although some of the billing from  
providers that demonstrated questionable billing on our measures may be 
legitimate, providers with questionable billing warrant further scrutiny.   
For each provider we identified, we calculated the dollar amount that 
Medicare paid for services associated with each measure on which the 
provider demonstrated questionable billing.  To do so, we summed the 
amount that Medicare paid for all claims associated with the measure(s) 
for which the provider demonstrated questionable billing.  This was not 
necessarily the total amount that Medicare paid the provider for 
ophthalmology services.  For example, if a provider demonstrated 
questionable billing only for Lucentis injections, we summed all Lucentis 
injections billed by that provider. 
We also identified geographic areas that had high rates of Medicare 
payments associated with questionable billing for ophthalmology services 
in 2012. We also reviewed multiple data sources to identify providers 
with listed specialties that appeared unrelated to ophthalmology (i.e., 
specialties other than ophthalmology, optometry, or ambulatory surgery).  
Specifically, we reviewed the specialty code field from Medicare claims  
data; specialty information from  the Provider Enrollment, Chain, and 
Ownership System (PECOS); and specialty information from the National 
Plan and Provider Enumeration System (NPPES).19   We report the extent 
to which providers with specialties thatappeared unrelated to 
ophthalmology billed for ophthalmology services.  
Limitations   
We did not conduct a medical record review for any claims associated 
with the services in this report to determine whether they were  
inappropriate or fraudulent. Some providers may have legitimate reasons 
for exceeding certain thresholds on our measures of questionable billing.  
For example, they may be highly specialized providers that offer unique or 
complex care for beneficiaries.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
____________________________________________________________ 
19 To establish and maintain Medicare billing privileges, providers supply information  
about their specific attributes, including medical specialty and license information, to  
CMS through PECOS and NPPES.  For more information about PECOS and NPPES, see 
Appendix B.  
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  5 
     
   
FINDINGS 
Four percent of providers billing for ophthalmology 
services in 2012 demonstrated questionable billing on 
at least one of our measures; Medicare paid them 
$171 million for services related to these measures 
Of the 44,960 providers that billed Medicare for ophthalmology services 
in 2012, approximately 4 percent (1,726) exceeded the threshold for at 
least one of our nine measures of questionable billing.20  Overall, Medicare 
paid these 1,726 providers approximately $768 million for ophthalmology 
services in 2012.  Of this $768 million, Medicare paid $171 million for 
services associated with the measures on which the providers  
demonstrated questionable billing.21    
Among the 1,726 providers with questionable billing, 96 percent (1,653) 
exceeded the threshold for just one measure of questionable billing, and 
approximately 4 percent (64) exceeded the threshold for two measures of 
questionable billing.  Nine providers exceeded our thresholds for three, 
four, or five measures of questionable billing.  Table 2 indicates the 
number and percentage of providers by the number of measures of 
questionable billing for which providers exceeded thresholds.  Appendix C 
has the number and percentage of providers by the number of measures on 
which they demonstrated questionable billing within each specialty 
stratum.  
Table 2.  Number and Percentage of Providers by Number of Measures of  
Questionable Billing for Which Providers Exceeded Thresholds, 2012 
Number of Measures of Questionable Billing for  Number of  Percentage of 
Which Providers Exceeded Thresholds   Providers  Providers 
1  1,653   95.8%  
2  64   3.7%  
3  7  0.4%  
4  1  <0.1% 
5  1  <0.1%  
6 or more   0  0%  
    Total   1,726   100% 
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
 
____________________________________________________________ 
20 Some claims  were processed by contractors that had one or more LCDs in  2012  
pertaining to  (a) tests that diagnose wet AMD or (b) Lucentis injections to treat wet 
AMD.   We excluded claims for tests to  diagnose wet AMD or Lucentis injections to treat 
wet AMD that  were processed by contractors having such LCDs in 2012.   The 
44,960  providers referenced in the text is the total number of providers that billed  for at 
least one claim that we did not exclude.   
21 Throughout the findings, we  will refer to this $171 million figure as the amount that 
Medicare paid for services associated with our measures of questionable billing. 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  6 
     
   
For each measure of questionable billing, Table 3 shows the total number 
of providers that exceeded the threshold for unusually high billing and the 
total Medicare payments to those providers for services associated with 
each measure.  Our nine measures of questionable billing are grouped into 
four categories. Appendix D shows the median, the threshold that 
indicated unusually high billing, the range of unusually high billing, the 
number of providers with unusually high billing, and the total amount 
Medicare paid these providers for services associated with each measure 
within each stratum.    
Table 3. Providers With Unusually High Billing by  Category  and Measure of Questionable Billing,  2012 
Amount Medicare Paid 
Category and Measure of Questionable Billing   Number of Providers  for Services  Associated  
Exceeding Threshold*  
With Each Measure**  
Providers with unusually  high billing for procedures to treat                                 261                           $91 million  
wet AMD      
- Lucentis injections more often than 28 days per  209  $68 million 
eye     
- Lucentis injections beyond the maximum annual  6  $22 million 
dosing recommendation per eye      
- Laser surgeries with concurrent biologic injections  50  $22 million 
or drug administration      
Providers with unusually high billing for complex cataract                                  580                           $39 million  
surgeries 
Providers with unusually high billing for tests to diagnose                                  355                           $23 million  
wet AMD       
- More than three annual fundus photography exams  273  $12 million 
- More than five annual ophthalmoscopy exams   88    $8 million 
- More than five annual fluorescein angiographies or  19    $3 million  
indocyanine green angiographies    
Providers with unusually high billing for ophthalmology                                 586                           $18 million  
claims using modifiers        
- Modifier 24 or 25   566  $18 million 
- Modifiers 22    20    $0.2 million 
   Total                               1,726                        $171 million 
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
* Column does not sum to  total because some providers were above the threshold on multiple measures of questionable billing.  
** Column does not sum to total due to rounding.  
 
Relatively few providers demonstrated questionable billing for 
procedures to treat wet AMD; however, over half of Medicare 
payments associated with questionable billing went to such 
providers for treating wet AMD  
Of the 1,726 providers demonstrating questionable billing on any of our 
measures in 2012, 261 (15 percent) did so on at least one of our three 
measures for procedures that treat wet AMD.  Medicare paid these 
providers $91 million for procedures that treat wet AMD, including 
Lucentis injections and laser surgeries.  These services represented the 
majority (53 percent) of Medicare payments associated with our measures 
of questionable billing. Some contractors have established limitations on 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  7 
     
   
the frequency at which providers may bill for these procedures.22 In areas 
without these limitations, providers that bill for these procedures at 
unusually high levels may be billing for services that are not medically 
reasonable or necessary.  
Lucentis injections more often than 28 days per eye. In 2012, 
209 providersalmost all of whom  were ophthalmologists (206)billed 
for an unusually high percentage of Lucentis injections sooner than 
28 days after a prior injection on the same eye.  Medicare paid these 
providers $68 million for Lucentis injections in 2012.   
The 206 ophthalmologists demonstrating questionable billing on this 
measure billed for more than 6 percent of their Lucentis injections within 
28 days of a prior injection on the same eye.  One provider billed for 
56 percent of his Lucentis injections (121 of 216) less than one month 
after a prior injection on the same eye.  In total, Medicare paid this 
provider $215,153 for Lucentis injections in 2012.  This raises questions 
about the medical necessity of these injections.  
Lucentis injections beyond the maximum annual dosing recommendation 
per eye. Additionally, 6 providersall ophthalmologistsbilled for 
Lucentis injections beyond the maximum annual dosing recommendation 
per eye (i.e., more than 12 or 13 injections per eye per year) for an 
unusually high percentage of beneficiaries.23 Medicare paid these 
providers $22 million in 2012 for Lucentis injections.   
Overall, only 56 providers billed for more than the maximum annual 
dosing recommendation per eye for Lucentis injections in 2012.  Of these 
providers, 6 billed for more than 12 or 13 Lucentis injections per eye for at 
least 9 percent of beneficiaries. One particular provider billed for Lucentis  
injections beyond the maximum recommended dosing amount for 12 of 
his 106 beneficiaries. This provider billed for an average of 19 injections 
for each of these 12 beneficiaries, including billing for 34 injections for 
1 beneficiary.  Overall, Medicare paid this provider $2 million for 
Lucentis injections in 2012. This raises questions about whether all of 
these injections were medically reasonable and necessary. 
 
____________________________________________________________ 
22 For our analysis of providers  in areas where contractors have established LCDs 
limiting procedures that treat wet AMD, see our earlier report:  Medicare Paid 
$22  Million in 2012 for Potentially Inappropriate Ophthalmology Claims, 
OEI-04-12-00281, December 2014. 
23 The FDA-approved Lucentis label states that the biologic  may be administered as  often  
as every 28 days to treat wet AMD, for a total of 12  or 13 injections per eye per year, 
depending  on  when the first injection  was administered, but that it can also  be effective if 
injected as infrequently as once every 3 months. 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  8 
     
   
Laser surgeries with concurrent biologic injections or drug 
administration. In 2012, 50 providers billed for laser surgery within 
28 days of biologic injections or drug administration for an unusually high 
percentage of beneficiaries.  Medicare paid these providers $22 million for  
procedures to treat wet AMD in 2012. 
The vast majority of providers (3,137 of 3,612) that billed for procedures 
to treat wet AMD in 2012 did not bill for any laser surgeries within 
28 days of biologic injections or drug administration in 2012.  However, 
1 provider billed for laser surgery within 28 days of Lucentis injections or 
drug administration for 80 percent of his beneficiaries (540 of 673).  To 
treat these 540 beneficiaries wet AMD, this provider billed for 
6,748 Lucentis injections and 2,741 laser surgeries, representing 
$16 million.  This figure includes 21 beneficiaries for whom this provider 
billed at least 24 Lucentis injections and 13 laser surgeries each.  This 
raises questions about the medical necessity of these procedures.   
Five hundred eighty providers demonstrated questionable 
billing for complex cataract surgery, and Medicare paid these 
providers $39 million for this procedure   
Approximately one-third of the providers demonstrating questionable 
billing on any of our measures (580 of 1,726) did so for billing an 
unusually high percentage of their overall claims for cataract surgery as 
complex cataract surgery.  Medicare paid these providers $39 million for 
complex cataract surgeries.  For most providers, complex cataract surgery 
comprised less than 2 percent of their claims for cataract surgery.  
However, 1 provider billed for almost all of his cataract surgeries (356 of 
369) as complex. Medicare paid this provider over $430,000 for complex 
cataract surgeries in 2012. 
Providers with an unusually high percentage of complex cataract surgeries 
may have a legitimate reason, such as specializing in complex cases.  
However, providers also may be billing unnecessarily for the complex 
surgeriesrather than for standard onesto increase their Medicare 
payments.  Medicare paid an average of $200 more per complex cataract 
surgery than per regular cataract surgery in 2012 because complex cataract 
surgeries require more resources to perform.     
Approximately 900 providers demonstrated questionable 
billing for our remaining 5 measures, and Medicare paid these 
providers $41 million for services related to these measures   
Additionally, approximately 900 providers demonstrated questionable 
billing on our remaining 5 measures.  Specifically, these measures include 
providers with unusually high billing for tests to diagnose wet AMD and 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  9 
     
   
for ophthalmology claims using modifiers.  Medicare paid these 900 
providers approximately $41 million in 2012 for exams to diagnose wet 
AMD and for ophthalmology claims with modifiers 22, 24, or 25.  Please 
see Appendix D for details about questionable billing by measure and 
provider specialty. 
In seven metropolitan areas, the percentage of 
Medicare payments associated with our measures of 
questionable billing was at least twice as high as it 
was nationally    
Nationally, 2.6 percent of Medicare payments for ophthalmology services 
were associated with the measures on which providers demonstrated 
questionable billing ($171 million of $6.7 billion). These Medicare 
payments went to providers located in 340 metropolitan areas.  However, 
in each of seven metropolitan areas, Medicare payments for services 
associated with our measures of questionable billing were an average of at 
least 7 percent of total Medicare payments for ophthalmology services.  
This is more than double the rate of Medicare payments for questionable 
billing nationally. See Table 4 for the percentage of Medicare payments 
for ophthalmology services associated with questionable billing by 
metropolitan area in 2012 and the number of providers demonstrating 
questionable billing in these areas.  
Table 4.  Percentage of Medicare Payments Associated With Questionable Billing in Areas With High Rates of 
Questionable Billing, 2012 
Percentage of  Medicare  Medicare Payments  Total Medicare 
Payments for Services  Associated With   Payments for  Number of Providers 
Associated with   Measures of  Ophthalmology   Demonstrating 
   Metropolitan Area    Questionable Billing   Questionable Billing   Services    Questionable Billing  
Huntington, WV   35.3%   $4.2 million   $11.8 million  1 
Vineland, NJ  31.4%  $5.0 million   $15.8 million  4 
Salisbury, MD   16.5%   $2.9 million   $17.5 million  3 
Miami, FL  12.2%  $21.2 million  $173.5 million  52 
Grand Rapids, MI   11.6%   $3.4 million   $29.8 million  6 
Fresno, CA   10.4%  $2.2 million   $21.4 million  4 
Cincinnati, OH   7.4%   $2.0 million   $27.5 million  7 
All Other Areas   2.0%  $129.9 million  $6.4 billion   1,649  
Total   2.6%   $171 million   $6.7 billion   1,726  
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
 
Even though these seven metropolitan areas account for only 5 percent of 
all providers with questionable billing (78 of 1,726), the providers in these 
areas were responsible for nearly one quarter of all Medicare payments 
associated with questionable billing ($41 million of $171 million).  Of this  
$41 million, most ($34 million) was for Lucentis injections.   
 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  10 
     
   
Medicare paid $2 million for ophthalmology services 
to 821 providers that were not listed as eye specialists 
in CMS databases 
Of the 44,960 providers that billed Medicare for ophthalmology services 
in 2012, 2 percent (821) of providers were not listed as eye specialists 
(i.e., not ophthalmologists, optometrists, or ambulatory surgery centers) in 
the Medicare claims data; the Provider Enrollment, Chain, and Ownership 
System (PECOS); and the National Plan and Provider Enumeration 
System (NPPES).24 Medicare paid these 821 providers just over 
$2 million in 2012 for ophthalmology services, including $57,000 for 
major surgeries, which are the most invasive eye surgeries.25 Although the 
data sources we reviewed indicated that these providers were licensed and  
certified to practice medicine, these providers were not listed as eye care 
specialists.26  Ophthalmology services billed by these providers may be of 
poor quality or inappropriate if the providers were not properly trained to 
perform such services.  
In total, Medicare paid these providers for 24,069 ophthalmology claims.  
Two Medicare contractors processed 53 percent of these claims (12,688), 
though their share of all Medicare claims for ophthalmology services was 
less than 30 percent in 2012.   
Additionally, another 131 providers did not have specialty codes on their 
Medicare claims noting that they were eye specialists.  However, their 
information in PECOS and/or NPPES noted that they were eye specialists.   
Therefore, the specialty codes on the Medicare claims differed from those 
in PECOS and/or NPPES for these providers.27 Differences in the 
specialty codes among these databases may indicate that these providers 
are not reporting and/or updating all specialty information. 
   
____________________________________________________________ 
24 The provider specialty code on Medicare claims is automatically populated by PECOS 
data, but  providers may have  more than  one specialty in PECOS.  Additionally, upon  
enrollment, providers are required to submit identifying information, such as name and  
specialty, to  NPPES. 
25 Major  surgeries provide a 90-day global surgery period, the longest of any global 
surgery period  in Medicare. 

26 Providers  do not have to  be listed as eye care specialists to  perform eye procedures.  

For example, a provider could be listed as a general surgeon  in PECOS while also  

licensed and certified as an ophthalmologist. 

27 Contractors are required to  verify providers information during enrollment and 

revalidation.  See Appendix B for information  on how providers enroll and revalidate in  

Medicare using PECOS  and NPPES.   

Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  11 
     
   
CONCLUSION AND RECOMMENDATIONS 
In 2012, Medicare paid $6.7 billion to 44,960 providers for services that 
screened for, diagnosed, evaluated, and treated wet AMD or cataracts.  
Recent investigations and prior OIG work have found that these 
ophthalmology services are vulnerable to fraud, waste, and abuse.   
In 2012, approximately 4 percent of providers (1,726) demonstrated 
questionable billing on at least one of our nine measures.  Medicare paid 
these providers $768 million for all ophthalmology services in 2012, of 
which $171 million was for services associated with the measures on 
which these providers demonstrated questionable billing.  While there may 
be legitimate reasons for some of this billing, these providers warrant 
further scrutiny.  Additionally, in seven metropolitan areas the percentage 
of Medicare payments associated with our measures of questionable 
billing was twice as high as it was nationally.     
Further, most providers billing for ophthalmology services, and those 
demonstrating questionable billing, were listed as eye specialists (i.e., 
ophthalmologists, optometrists, or ambulatory surgical centers) in CMS 
databases.  However, Medicare paid $2 million for ophthalmology 
services to 821 providers that were not listed as eye specialists. 
We recommend that CMS: 
Increase monitoring of billing for ophthalmology services 
CMS should increase its monitoring of billing for ophthalmology services.  
CMS could use many different methods to increase its monitoring of these 
services; these methods include but are not limited to: 
 	  Increasing its oversight of providers that demonstrated questionable 
billing on their use of Lucentis.  Injections of Lucentis represent a 
substantial financial vulnerability if billed inappropriately or  
fraudulently.  
 	  Instructing its contractors to use measures similar to those we 
incorporated into this study when monitoring billing for services that  
diagnose and treat wet AMD and cataracts.  CMS could develop 
thresholds for these measures and instruct its contractors to conduct 
additional reviews of providers that exceed them.  These contractors 
could also focus their efforts in the metropolitan areas with the highest  
percentages of questionable billing.   
 	  Including the measures of questionable billing used in this report in its 
fraud-prevention system. 
 	  Reviewing local policies (i.e., LCDs) regarding ophthalmology 
services used by its claims processing contractors.  For those with 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  12 
     
   
specific criteria and uniform thresholds (e.g., in line with FDA label 
requirements), CMS could create national policies to align with these 
criteria.  Additionally, CMS could instruct its claims processing 
contractors to review and consider implementing local policies used by 
other contractors to ensure that ophthalmology services are billed for 
appropriately.  
 	  Reviewing payments for ophthalmology services that are inconsistent 
with providers reported specialties.  
Review providers with questionable billing for ophthalmology  
services identified by this evaluation and take appropriate 
action 
In a separate memorandum, we will refer to CMS the providers with 
questionable billing for ophthalmology services in 2012.  We will also 
refer the providers that were not listed as eye specialists but that billed for 
major surgeries.  CMS and/or its contractors should assess the claims from 
these providers and, if warranted, review medical records, review billing 
patterns, and/or perform unannounced site visits.  After this assessment, 
CMS should determine and take an appropriate course of action.  
Appropriate actions may include, but are not limited to, (1) referring to 
law enforcement for criminal investigation, (2) suspending payments, 
(3) revoking Medicare privileges, (4) recouping overpayments, 
(5) educating providers on how to properly bill for ophthalmology services 
and report all specialties in which they may bill, or (6) taking no action.  
 
 
 
 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  13 
     
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with both of our recommendations.   
CMS concurred with our recommendation to increase monitoring of 
billing for ophthalmology services.  CMS stated that it will review the 
options that OIG included for how to implement this recommendation to 
determine which methods will be most effective.  CMS further noted that 
it is committed to protecting the Medicare Trust Funds by combatting 
fraud, waste, and abuse. 
CMS also concurred with our recommendation to review providers with 
questionable billing for ophthalmology services identified by this 
evaluation and take appropriate action.  CMS explained that it will 
conduct a preliminary analysis of the claims referred by OIG.  CMS stated 
that on the basis of this analysis, it will determine an appropriate number 
of claims on which to conduct medical review and take appropriate action 
For the full text of CMSs comments, see Appendix E.  
 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  14 
     
   
APPENDIX A 
 
Detailed Methodology  
Scope 
We analyzed paid Medicare Part B claims for 64 different HCPCS codes 
for ophthalmology services from the NCH File.  This included 
approximately 34 million paid claims billed by 44,960 unique providers in 
2012. 
Identifying Providers With Questionable Billing for 
 
Ophthalmology Services 
To ensure that each providers billing was compared to the providers 
peers, we classified each provider into one of four strata on the basis of the 
providers specialty, as noted in the specialty code field on the providers 
Medicare claim:  ophthalmology, optometry, ambulatory surgery, and all 
other specialties.28   We analyzed each specialty group separately.  See 
Table A-1 for the total number of providers and dollar amount that 
Medicare paid for ophthalmology services in each of these four strata in 
2012. 
Table  A-1.  Number of Providers and Dollar  Amount Medicare Paid for Ophthalmology Services  
by Specialty Strata, 2012  
Dollar Amount That Medicare  
Specialty Strata  Number of Providers in Strata  
Paid Providers in Strata 
Ophthalmologists  17,270   $5.0 billion  
Optometrists  24,737   $0.4 billion  
Ambulatory Surgical Centers   2,001   $1.3 billion  
All Other Providers*   952   <$0.1 billion 
   Total   44,960  $6.7 billion 
* There were 38 provider specialty types included in  this  specialty group. 
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
 
We developed nine measures of questionable billing for ophthalmology 
services to capture several different types of possible fraud, waste, and 
abuse. We grouped these nine measures of questionable billing into four 
categories. We developed two measures in the first categoryunusually 
high billing for procedures to treat wet AMDon the basis of the 
FDA-approved labelling for Lucentis. We developed the remaining seven 
measures on the basis of past OIG work and fraud investigations related to  
ophthalmology services, as well as input from staff at CMS and the 
____________________________________________________________ 
28 Some providers had two specialty codes in their Medicare claims data.  We classified  
these providers as eye specialists (i.e.,  ophthalmology, optometry, or ambulatory surgery)  
if one of their specialty codes  indicated such  a specialty.  For providers with more than  
one specialty code not for eye specialists, we classified them according to the specialty 
code under which they billed  for the greatest number of ophthalmology claims. 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  15 
     
   
American Academy of Ophthalmology.  See Table A-2 for the measures of 
questionable billing. 
Table  A-2:  Measures of Questionable Billing  
Category  Measure of Questionable Billing 
Providers with unusually high  Lucentis injections more often than 28 days per eye*  
billing for procedures to treat  Lucentis injections beyond maximum annual dosing recommendation per eye*  
wet AMD    Laser surgeries with concurrent biologic injections or drug administration  
Providers with unusually high  
billing for complex cataract  High percentage of claims for complex cataract surgery 
surgeries 
High number of fundus photography  exams per beneficiary annually*  
Providers  with unusually high   
High number of ophthalmoscopy  exams per beneficiary annually*  
billing for tests to diagnose wet 
High number of fluorescein angiographies or indocyanine green angiographies 
AMD 
per beneficiary annually*  
Providers  with unusually high    High percentage of claims with modifiers 24 or 25  
billing for ophthalmology claims  
High percentage of claims with modifier 22  
using modifiers  
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
* Some  contractors have LCDs establishing limitations on these services.  In  this report, we only applied this measure to providers with claims 
processing contractors not having such LCDs.  We included a comparable analysis for providers with claims processing contractors having LCDs that 
established limitations on  these services in a companion report, Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims, 
OEI-04-12-00281, December 2014. 
 
When analyzing each measure, we excluded claims submitted to claims  
processing contractors that had an LCD pertaining to the HCPCS codes  
related to the measure.  We also excluded providers that did not bill at 
least one claim with the HCPCS code or modifier related to the measure.  
Further, for each measure of questionable billing, we report only providers 
for which Medicare paid at least five ophthalmology claims associated 
with the measure in 2012.  
Using the Tukey method, we considered a providers billing to be 
unusually high, or questionable, on any of the nine measures if it was 
greater than the 75th percentile plus 1.5 times the interquartile range.29   
However, for some measures of questionable billing, our use of this 
methodology resulted in an outlier threshold that was the same as the 
higher bound of the interquartile range.  For these measures of 
questionable billing, as noted below, we performed a serial Tukey.  That 
is, we performed the Tukey method again on only those providers that 
exceeded the first outlier threshold.   
Additionally, we calculated the dollar amount that Medicare paid each 
provider for services associated with the measures on which they 
demonstrated questionable billing.  To do so, we summed the amount that 
Medicare paid for all claims having HCPCS codes and/or modifiers 
____________________________________________________________ 
29 This is a standard exploratory method for identifying members of a population  with  
unusually high values  on a given statistic compared to the rest of the population when  no  
established benchmarks exist.  See J.W. Tukey,  Exploratory Data  Analysis, 
Addison-Wesley, 1977. 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  16 
     
   
related to the measure(s) on which these providers demonstrated 
questionable billing. For example, if a provider demonstrated 
questionable billing only for Lucentis injections, then we summed all 
claims for Lucentis injections billed by that provider.  However, for this 
calculation we did not sum  the amount that Medicare paid the provider for 
any other ophthalmology services.     
Below are the four categories of questionable billing, including their 
associated nine measures. 
A. 	  Providers with unusually high billing for procedures to treat wet AMD. 
We reviewed claims for certain procedures that treat wet AMD to analyze 
three measures of questionable billing.  These are:  
1.  Lucentis injections more often than 28 days per eye. 	This measure 
represents the percentageout of all Lucentis injections for the 
provider billedof Lucentis injections that a provider billed less than 
28 days after a prior injection on the same eye. 
Providers billing for an unusually high percentage of Lucentis 
injections sooner than 28 days after another injection on the same eye 
may be overutilizing Lucentis and/or billing Medicare for unused 
Lucentis. According to the FDA-approved dosing guidelines on 
Lucentiss label, the most frequently one eye should receive an 
injection is every 28 days. However, the dosing guidelines also 
indicate that Lucentis remains effective if dosed as infrequently as 
every 3 months per eye.  
2.  Lucentis injections beyond the maximum annual dosing 
recommendation per eye. This measure represents the percentage 
out of all beneficiaries for whom the provider billed for Lucentis 
injectionsof beneficiaries for whom a provider billed for Lucentis 
injections beyond the maximum annual dosing recommendations per 
eye. We performed a serial Tukey to identify outliers on this measure. 
Providers exhibiting this measure may be overutilizing Lucentis and/or 
billing Medicare for unused Lucentis. Medicare paid an average of 
$2,000 for each dose of the biologic, which is injected directly into the 
eye. According to the FDA-approved dosing guidelines on Lucentiss 
label, an eye should receive a maximum of 12 or 13 injections per year 
(depending on when the first injection occurs).  However, the dosing 
guidelines also indicate that Lucentis remains effective if dosed as 
infrequently as every 3 months per eye.   
3.  Laser surgeries with concurrent biologic injections or drug 
administration. This measure represents the percentageout of all 
beneficiaries for whom the provider billed for procedures to treat wet 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  17 
     
   
AMDof beneficiaries for whom a provider billed for laser surgeries 
to treat wet AMD within 28 days of Lucentis injections or drug 
administration to treat wet AMD on the same eye.  We performed a 
serial Tukey to identify outliers on this measure. 
Laser surgery is appropriate to treat wet AMD in only limited  
circumstances, and most physicians do not treat wet AMD with 
concurrent laser surgery and biologic injections or drug administration.  
Specifically, providers may be billing Medicare for financial gain or 
potentially harming their patients if  they bill for and/or provide laser 
surgeries with biologic injections or drug administration to treat wet 
AMD. 
B. 	  Providers with unusually high billing for complex cataract surgeries. This 
category has only one measure of questionable billing, which is: 
4. 	  High percentage of claims for complex cataract surgeries. This 
measure represents the percentage of each providers overall claims for 
cataract surgery claims that were for complex cataract surgery.   
Medicare pays providers a higher rate for complex cataract surgeries 
than for standard cataract surgeries.  Providers with an unusually high 
percentage of claims for complex cataract surgery may be billing for 
services that are not medically reasonable or necessary.   
C.  	 Providers with unusually high billing for tests to diagnose wet AMD. 
Billing for an unusually high number of tests per eye for an unusually high  
percentage of beneficiaries may indicate that providers are billing for 
services that are not medically reasonable or necessary.  Additionally,  
these diagnostic exams cause blurred vision, which forces patients to 
require temporary care, and can harm  beneficiaries if the tests are not 
needed. We reviewed claims for three types of tests that diagnose wet 
AMD. These three types of tests are the basis of our three measures of 
questionable billing, which are: 
5. 	  High number of fundus photography exams per beneficiary annually. 
Providers billing for an unusually high number of fundus photography 
exams for an unusually high percentage of beneficiaries may be billing 
for services that are not medically reasonable and necessary.  Overall, 
approximately 2 million beneficiaries had fundus photography exams 
in 2012. We identified the total number of these exams that each 
provider billed for each beneficiary.    
Some contractors have LCDs that establish limits on the number of 
annual fundus photography exams that are appropriate for providers 
within their jurisdiction, and these limits vary across LCDs.  
Therefore, for providers in our analysis (i.e., those in jurisdictions 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  18 
     
   
without LCDs), we used the Tukey methodology to determine a 
threshold for an unusually high number of exams per eye annually.  
The resulting threshold was two exams per eye, annually.   
We then used the Tukey methodology to identify providers that billed 
for more than three fundus photography exams per eye annually on an 
unusually high percentage of their beneficiaries receiving these exams 
in 2012. We performed a serial Tukey to identify outliers on this 
measure. 
6. 	  High number of ophthalmoscopy exams per beneficiary annually. 
Providers billing for an unusually high number of ophthalmoscopy 
exams for an unusually high percentage of beneficiaries may be billing 
for services that are not medically reasonable and necessary.  Overall, 
approximately 800,000 beneficiaries had ophthalmoscopy exams in 
2012. We identified the total number of these exams that each 
provider billed for each beneficiary.    
Some contractors have LCDs that establish limits on the number of 
annual ophthalmoscopy exams that are appropriate for providers 
within their jurisdiction, and these limits vary across LCDs.  
Therefore, for providers in our analysis (i.e., those in jurisdictions 
without LCDs), we used the Tukey methodology to determine a 
threshold for an unusually high number of exams per eye annually.  
The resulting threshold was five exams per eye, annually.   
We then used the Tukey methodology to identify providers that billed 
for more than five ophthalmoscopy exams per eye annually on an 
unusually high percentage of their beneficiaries receiving these exams 
in 2012. We performed a serial Tukey to identify outliers on this 
measure.     
7.	   High number of fluorescein angiographies or indocyanine green 
angiographies per beneficiary annually. Providers billing for an 
unusually high number of fluorescein angiographies or indocyanine 
green angiographies for an unusually high percentage of beneficiaries 
may be billing for services that are not medically reasonable and 
necessary.  Overall, approximately 350,000 beneficiaries had 
fluorescein angiographies or indocyanine green angiographies in 2012.  
We identified the total number of these exams that each provider billed 
for each beneficiary.    
Some contractors have LCDs that establish limits on the number of 
annual fluorescein angiographies or indocyanine green angiographies 
that are appropriate for providers within their jurisdiction, and these 
limits vary across LCDs.  Therefore, for providers in our analysis (i.e., 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  19 
     
   
those in jurisdictions without LCDs), we used the Tukey methodology 
to determine a threshold for an unusually high number of exams per 
eye annually.   The resulting threshold was five exams per eye, 
annually.   
We then used the Tukey methodology to identify providers that billed 
for more than five fluorescein angiographies or indocyanine green 
angiographies per eye annually on an unusually high percentage of 
their beneficiaries receiving these exams in 2012.  We performed a 
serial Tukey to identify outliers on this measure.     
D. 	  Providers with unusually high billing for ophthalmology claims using 
modifiers. Past OIG work has found that some providers inappropriately 
used modifiers to increase Medicare payments.30   We reviewed claims for 
the presence of modifiers that cause Medicare to cover E&M services that 
it otherwise would not. This category has two measures of questionable 
billing. These are:  
8. 	  High percentage of claims with modifiers 24 or 25. This measure 
represents the percentage of each providers claims that contained 
modifiers 24 or 25. These modifiers indicate that E&M services 
provided during global surgery periods are separately payable because 
they are not related to the concurrent global surgery.  However,  
providers that submit an unusually high percentage of claims with 
modifiers 24 or 25 may be using the modifiers to inappropriately 
receive payment for these services.   
9. 	  High percentage of claims with modifier 22. This measure represents 
the percentage of each providers claims that contained modifier 22.  
This modifier causes Medicare to separately pay for E&M visits 
provided during global surgery periods because beneficiaries had 
particularly complicated surgeries that would require additional E&M 
visits beyond what is covered in the global surgery period.  Providers 
that submit an unusually high percentage of claims with this modifier 
may be using it to inappropriately receive payment for E&M services.   
Describing Providers With Questionable Billing for 

Ophthalmology Services  
 
To describe providers with questionable billing for ophthalmology 
services, we analyzed the geographic locations of the questionable billing 
providers. 
We identified each providers Core Base Statistical Area (CBSA) by using 
the zip code listed on the providers ophthalmology claims.  A CBSA is a 
____________________________________________________________ 
30 For example, see OIG, Use of Modifier 25, OEI-07-03-00470.  November 2005. 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  20 
     
   
region around an urban center that has at least 10,000 people.  For each 
CBSA, we determined the total dollar amount that Medicare paid to 
providers that demonstrated questionable billing for services associated 
with our measures of questionable billing.  We also determined, for each 
CBSA, the dollar amount that Medicare paid in total for ophthalmology 
services. In the body of the report, we refer to CBSAs as metropolitan 
areas.  
After identifying the dollar amount Medicare paid for services associated 
with the measures on which providers demonstrated questionable billing, 
we identified CBSAs with high rates  of Medicare payments for services 
associated with our measures of questionable billing out of total Medicare 
payments for ophthalmology services in 2012.  We limited our analysis to 
only CBSAs with at least three providers billing for a total of at least 
$2 million for ophthalmology services in 2012.  In the findings, we report 
CBSAs with percentages of Medicare payments for services associated 
with our measures of questionable billing that were at least twice the 
national average (2.6 percent). We  also determined the measures of 
questionable billing exhibited by providers in these CBSAs. 
Analyzing the Specialty Information of Providers Billing for 
Ophthalmology Services   
We identified each providers medical specialty based on the specialty 
code listed on the providers ophthalmology claims.  This information is 
supplied directly by the PECOS database for each provider.   We then 
determined, by specialty, the total amount that Medicare paid for all 
ophthalmology services in 2012.  We  identified providers that had 
specialty codes indicating that they were not eye specialists (i.e., not 
ophthalmologists, optometrists, or ambulatory surgical centers).  
Subsequently, we compared these providers specialty codes on their 
Medicare claims with specialty information from PECOS and NPPES to 
identify those that were not listed as eye specialists in any data source. We  
also determined which claims processing contractors processed claims for 
these providers.  
   
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  21 
     
   
APPENDIX B   
Provider Enrollment Data and Claims Processing  
Before enrolling in Medicare, providers must first obtain a National 
Provider Identifier (NPI) through NPPES.31   To do so, providers are 
required to submit identifying information to NPPES, such as name, 
professional license number, specialty type, and practice location.   
Claims processing contractors then enroll providers in Medicare using 
PECOS.  Providers submit an enrollment application that claims  
processing contractors review, validate, and submit into PECOS.  This 
application includes provider license or certification information, specialty 
type, practice address location, and other identifying information.32    
Once providers are enrolled, CMS and its contractors oversee the 
providers by using the information in PECOS.  Providers must report any 
changes in their information to claims processing contractors within 
90 days.33  Claims processing contractors may deactivate the billing 
privileges of providers that do not maintain accurate enrollment 
information.34   Additionally, providers must revalidate their enrollment 
information every 5 years by resubmitting enrollment applications and 
supporting documentation to claims processing contractors for review and 
validation.35  
Contractors use data from PECOS to  process and pay Medicare claims.  
For example, providers specialty types and practice addresses on 
Medicare claims come  directly from PECOS.  
 
   
____________________________________________________________ 
31 42 CFR   424.506(b); CMS Medicare Program Integrity  Manual, Pub. No. 100-08,  
ch. 15,  15.3. 
 
32 CGI Federal, PECOS 6.0.0 Required Fields, Doc ID:  PECOS-6.0.0-REQ-67792-
v0.10, April 2009.  Providers must list a primary specialty when enrolling in Medicare 

using PECOS.  Providers  have the option of  reporting a secondary specialty in PECOS, 
 
but they cannot list any other specialties on the same enrollment application. 

33 42 CFR   424.516(d)(2). 
34 42 CFR   424.540(a)(2); CMS, Medicare Program  Integrity Manual, Pub. No. 100-08, 

ch. 15,  15.27.1.  

35 42 CFR   424.515.   Ambulances and suppliers of durable medical equipment have 

different timeframes for revalidation.  
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  22 
     
   
APPENDIX C   
Providers That Exceeded Thresholds for Questionable Billing, by Specialty  
Strata and Number of Measures, 2012  
Number of Measures for Which  
Providers Exceeded Thresholds of 
Specialty Strata   Questionable Billing   Number of Providers  
1  1,120  
2  60 
3  7 
Ophthalmologists  4  1 
5  1 
6 or more   0 
Total  1,189  
1  423 
2  2 
Optometrists 
3 or more   0 
Total  425 
1  98 
Ambulatory Surgical  2  2 
Centers   3 or more   0 
Total  100 
1  12 
Other Provider 
2 or more   0 
Specialties  
Total  12 
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
 
 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  23 
     
   
APPENDIX D 
Providers With Unusually High Billing by Each Measure of Questionable 
Billing, 2012 
Table D-1. Ophthalmologists With Unusually High Billing by Each Measure of 
Questionable Billing, 2012 
Providers with Unusually High Billing  
Medicare 
Payments for  Number of  
Lower and  Services   Providers 
Number of   Upper  Associated With   Exceeding 
Measure of Questionable Billing   Providers   Quartiles*  Threshold  Range   Each Measure**  Threshold*** 
Providers with unusually high billing for   $90 million   249 
procedures to treat wet AMD              
- Lucentis injections more often than 28  2,186   0.0% to 2.5%   6.3%   6.3% to 56.0%   $68 million  206 
days per eye             
- Lucentis injections beyond the  2,186   0.0% to 0.0%   8.5%   9.1% to 11.8%   $22 million  6 
maximum annual dosing             
recommendation per eye                
- Laser surgeries with concurrent  3,361   0.0% to 0.0%   6.8%   7.1% to 80.2%   $22 million  41 
biologic injections or drug             
administration              
Providers with unusually high billing for   11,327   1.5% to 15.4%   36.3%   36.4% to 100%   $24 million   460 
complex cataract surgeries             
Providers with unusually high billing for   $23 million   271 
procedures to treat wet AMD              
-More than three annual fundus  10,393   0.0% to 0.0%   10.2%   10.3% to 57.1%   $11 million  201 
photography exams                
- More than five annual  7,436   0.0% to 0.0%   19.5%   19.5% to 59.4%    $8 million  76 
ophthalmoscopy exams                
- More than five annual fluorescein  4,366   0.0% to 0.0%   16.3%   16.7% to 50.0%    $3 million  19 
angiographies or indocyanine green             
angiographies               
Providers with unusually high billing for  
ophthalmology claims using modifiers          $12 million   261 
- Modifiers 24 or 25  13,898   0.8% to 11.1%  41.9%  41.9% to 100%  $12 million   242 
- Modifier 22   241  <0.1% to 0.2%   0.8%  0.8% to 4.9%    $0.2 million  19 
   Total**     $150 million  1,189  
* The lower quartile is the value for the  25th percentile; the  upper quartile is the value for the 75th  percentile, and their difference is  the interquartile range. 

** Column may not sum to total because of rounding. 

*** Sum of column exceeds total because some  providers were above the threshold on multiple measures of questionable billing. 
 
 For this measure, we performed a serial Tukey to identify outliers.  For more  information, see Appendix A. 
Source:  OIG analysis of 2012 NCH Part  B file, 2014.  
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  24 
     
   
APPENDIX D (CONTINUED)  
Providers With Unusually High Billing by Each Measure of Questionable 
Billing, 2012 
Table D-2. Optometrists With Unusually High Billing  by Each Measure of  
Questionable Billing, 2012 
Providers with Unusually High Billing  
Medicare 
Payments for  Number of  
Lower and  Services   Providers 
Number of   Upper  Associated With   Exceeding 
Measure of Questionable Billing   Providers   Quartiles*  Threshold  Range   Each Measure**  Threshold*** 
Providers with unusually high billing for   $0  0 
procedures to treat wet AMD              
- Lucentis injections more often than 28  4  0.0% to 0.0%   0.0%   0.0%  $0  0 
days per eye              
- Lucentis injections beyond the  4  0.0% to 0.0%   0.0%   0.0%  $0  0 
maximum annual dosing             
recommendation per eye               
 
- Laser surgeries with concurrent biologic  8  0.0% to 0.0%   0.0%  0.0%  $0 0 
injections or drug administration      
Providers with unusually high billing for   12,439   0.0% to 0.0%   40.9%   41.7% to 100%   <$0.1 million   26 
complex cataract surgeries             
Providers with unusually high billing for   $1 million   76 
tests to diagnose wet AMD              
-More than three annual fundus  15,675   0.0% to 0.0%   8.2%   8.3% to 53.7%    $0.6 million  64 
photography exams                
- More than five annual ophthalmoscopy  4,637   0.0% to 0.0%   5.3%   6.3% to 30%   <$0.1 million  12 
exams                
- More than five annual fluorescein  124  0.0% to 0.0%   0.0%   0.0%  $0  0 
angiographies or indocyanine green             
angiographies             
Providers with unusually high billing for   $5 million   325 
ophthalmology claims using modifiers             
- Modifiers 24 or 25  7,029   0.8% to 11.1%  42.0%  42.1% to 90.9%    $5 million  324 
- Modifier 22  14  0.2% to 1.4%  4.7%  9.8% to 9.8%  <$0.1 million  1 
   Total**    $6 million   425 
* The lower quartile is the value for the  25th percentile; the  upper quartile is the value for the 75th  percentile, and their difference is  the interquartile range. 

** Column may not sum to total because of rounding. 

*** Sum of column exceeds total because some  providers were above the threshold on multiple measures of questionable billing. 
 
 For this measure, we performed a serial Tukey to identify outliers.  For more  information, see Appendix A. 
Source:  OIG analysis of 2012 NCH Part  B file, 2014.   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  25 
     
   
APPENDIX D (CONTINUED)  
Providers With Unusually High Billing by Each Measure of Questionable 
Billing, 2012 
Table D-3.  Ambulatory Surgical Centers With Unusually High Billing by Each  
Measure of Questionable Billing, 2012 
Providers with Unusually High Billing  
Medicare 
Payments for  Number of  
Lower and  Services   Providers 
Number of   Upper  Associated With   Exceeding 
Measure of Questionable Billing   Providers   Quartiles*  Threshold  Range   Each Measure**  Threshold*** 
Providers with unusually high billing for   $1 million   12 
procedures to treat wet AMD              
- Lucentis injections more often than 28  31  0.0% to 2.1%  5.3%   5.8% to 10.6%    $0.5 million  3 
days per eye             
- Lucentis injections beyond the  31  0.0% to 0.0%   0.0%   0.0%  $0  0 
maximum annual dosing             
recommendation per eye               
- Laser surgeries with concurrent  235  0.0% to 0.0%   15.0%   16.7% to 46.7%   <$0.1 million  9 
biologic injections or drug             
administration              
Providers with unusually high billing for   1,968   1.7% to 9.8%   21.9%   22.0% to 86.3%   $14 million   90 
complex cataract surgeries             
Providers with unusually high billing for   $0  0 
tests to diagnose wet AMD              
-More than three annual fundus  0  0.0%   0.0%   0.0%  $0  0 
photography exams               
- More than five annual  0  0.0%   0.0%   0.0%  $0  0 
ophthalmoscopy exams               
- More than five annual fluorescein  0  0.0%   0.0%   0.0%  $0  0 
angiographies or indocyanine green             
angiographies             
Providers with unusually high billing for   $0  0 
ophthalmology claims using modifiers             
- Modifiers 24 or 25  0  0.0%   0.0%   0.0%  $0    0 
- Modifier 22   11  <0.1% to 0.8%   3.0%   0.0%  $0  0 
   Total**     $15 million  100  
* The lower quartile is the value for the  25th percentile; the  upper quartile is the value for the 75th  percentile, and their difference is  the interquartile range. 

** Column may not sum to total because of rounding. 
  
*** Sum of column exceeds total because some  providers were above the threshold on multiple measures of questionable billing. 
 
 For this measure, we performed a serial Tukey to identify outliers.  For more  information, see Appendix A. 
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  26 
     
   
APPENDIX D (CONTINUED)  
Providers With Unusually High Billing by Each Measure of Questionable 
Billing, 2012 
Table D-4. Providers in Other Specialties With Unusually High Billing by Each 
Measure of Questionable Billing, 2012 
Providers with Unusually High Billing  
Medicare 
Payments for  Number of  
Lower and  Services   Providers 
Number of   Upper  Associated With   Exceeding 
Measure of Questionable Billing   Providers   Quartiles*  Threshold  Range   Each Measure**  Threshold 
Providers with unusually high billing for   $0  0 
procedures to treat wet AMD              
- Lucentis injections more often than 28  4  0.0% to 3.2%   7.0%   0.0%  $0  0 
days per eye             
- Lucentis injections beyond the  4  0.0% to 0.0%   0.0%   0.0%  $0  0 
maximum annual dosing             
recommendation per eye               
- Laser surgeries with concurrent  8  0.0% to 0.0%   0.0%   0.0%  $0  0 
biologic injections or drug             
administration              
Providers with unusually high billing for   58  0.0% to 0.0%   25.0%   26.9% to 80.0%   $0.1 million   4 
complex cataract surgeries             
Providers with unusually high billing for   <$0.1 million   8 
tests to diagnose wet AMD              
-More than three annual fundus  165  0.0% to 0.0%   6.0%   7.7% to 16.7%   <$0.1 million  8 
photography exams                
- More than five annual  51  0.0% to 0.0%   4.0%   0.0%  $0  0 
ophthalmoscopy exams               
- More than five annual fluorescein  23  0.0% to 0.0%   0.0%   0.0%  $0  0 
angiographies or indocyanine green             
angiographies             
Providers with unusually high billing for   $0  0 
ophthalmology claims using modifiers             
- Modifiers 24 or 25  331  17.3% to 75.0%   NA   NA  NA  NA 
- Modifier 22   0  0.0%   0.0%   0.0%  $0  0 
   Total**     $0.1 million  12  
* The lower quartile is the value for the  25th percentile; the  upper quartile is the value for the 75th  percentile, and their difference is  the interquartile range. 
** Column may not sum to total because of rounding. 
 For this measure, we performed a serial Tukey to identify outliers.  For more  information, see Appendix A. 
  The threshold for  questionable billing was above 100 percent; therefore, there were no outliers on this  measure in this specialty stratum.  
Source:  OIG analysis of 2012 NCH Part  B file, 2014. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  27 
    APPENDIX E 
Agency Comments 
DEPARTMENT OF HEALTH & HUMA1\J SERVICES 
?00 lt>:lf>P<lodence Avonue SW 
Washmgton. DC 20201 
TO:  Daniel R. Levinson 
Inspector General 
FR0\1:  Andrew 1vf. Slavin 
Acting Administrator 
SVBJECI':  Otlice of Inspector General (OJG) Draft Report: "Questionable Billing for 
Medicare Ophthalmology Services (OEI-04-12-00280) 
The Centers for Medicare & Medicaid Services (Cl\fS) appreciates the opportunity to revkw and 
comment on the Office of Inspector General's (OIG) draft report.  CMS is C{)mmitted to 
protecting the Medicare Trust Funds by comba!ting fraud, waste, and abuse. 
To combat fraud, waste. and abuse in Medicare, CMS is using a comprehensive program 
integrity strategy to educate providers, recoup improper payments, and protect taxpayer dollars. 
Specific to ophthalmology claims, CMS released educational materials in July 2014 on 
ophthalmological benefits to educate physicians and other providers on the coverage and billing 
requirements for ophthalmological services. 1 The materials provide guidance on the billing 
requirements for catan1ct surgt,rics, tests to diagnose wet age-related macular degeneration 
(AMD). and procedures to treat wet AMD. Another educational tool for providers is the 
Comparative Billing Report (CBR). CBRs arc an educational tool designed to assist providers by 
providing high level data that allows them to compare their billing patterns to their state and 
national peers. In April 2015, CMS sent out l 0,000 CBRs to pruvidcrs who submitted claims for 
extracapsular cataract removals, general ophthalmological services, and evaluation and 
management (E.iM) services. OIG found that most providers that billed Medicare for 
ophthalmology services did not demonstrate questionable billing on any of OIG's measures in 
2012. 
In addition to prevention and education etl'orts. CMS is working to recover improper payments 
for ophthalmology claims. OIG's recently issued report on potential improper payments for 
ophthalmology claims identified claims that mav have inappropriately billed for certain services, 
including services that diagnose or treat cataracts or wet A~1D.2 CMS is currently working to 
determine the validity of claims that OJG identillcd as pot..::ntially inappropriate in that report and 
will take appropriate action with rt.'Sp<.>ct to those claims. 
To identify providers with questionable billing, CJ\!S has implemented the Fraud Prevention 
System, (FPS) which applies predictive analytic technology on claims prior to payment to 
identify aberrant and suspicious billing patterns. TI1e FPS nms predictive algorithms and other 
1 Medicare Vision Ser\'icrs, Mt"<licnre Learning Nc1work, ICN 907165, July 2014 

1 Mcdicar~ Paid S22 ;~li/lion in lOll for l'otenlial~v Jnapproprlal~ VphthalmoloJO' Claims, OEI-04 t2-0028! 

Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  28   
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  29 
     
   
 
   
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  30 
     
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office, and Jaime Stewart, Deputy Regional Inspector General.  
Evan Godfrey served as the lead analyst.  Central office staff who 
provided support include Clarence Arnold, Scott Horning, Scott Manley, 
David Tawes, and Christine Moritz.  
 
Questionable Billing for Medicare Ophthalmology Services (OEI-04-12-00280)  31 
     
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.