Inappropriate Billing by Optometrists Could Result in An Audit and Significant Repayment

Tuesday, January 15, 2013

By Thu Pham, O.D., and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Optometrists' scope of practice has expanded significantly in the last 10 years.  With that expansion has come a more complicated medical billing process.  Inappropriate billing could result in an audit by insurance companies, the state Medicaid program, the Medicare program or other third party payors, and a request for repayment of the amount of money paid due to the inappropriate billing, failure to maintain adequate documentation or other errors or omissions.

An Example of What is Considered Inappropriate Billing for Optometrists.

One example of inappropriate billing and coding is as follows.

Meibomian Gland Dysfunction (MGD) causes abnormal lipid production.  This may result in conditions such as dry eyes and chalazions.  Patients can suffer severe discomfort as a result  of MGD.  Treating MGD has become pivotal in the practice of optometry.  However, there is no specific International Classification of Disease (ICD)-9 code for MGD.  The most appropriate code to use appears to be 373.00 (Unspecified Blepharitis).  Some optometrists have used 373.12 (Internal Hordeolum) as the diagnosis code.  This does not appear to be the appropriate code to use.

The only Current Procedure Terminology (CPT) code an optometrist can legally use to bill for the diagnosis is the code for an office visit, such as 92012 or 99202, for example.  The only exception to this rule is if the optometrist has a LipiFlow Thermal Pulsation System, which is used to evacuate the meibomian glands.  The optometrist may then bill for the evacuation.  Some optometrists have used other surgical CPT codes in order to obtain higher reimbursements; this is generally impermissible.


Insurance companies, Medicare or Medicaid may pay the optometrist for the higher rates incorrectly billed for additional procedures.  However, when an optometrist gets audited, the optometrist may be required to pay back the money previously received.  In many cases, an insurer or state or federal health care program may even use a statistical extrapolation formula that multiplies the amount of repayment many times over.  Additionally, the inappropriate billing could be interpreted by insurance companies, Medicare and Medicaid as fraudulent billing.  Regardless, the optometrist could receive fines, penalties and interest, and removal from the provider’s panel or termination from the program.

An attorney at The Health Law Firm, Lance O. Leider, wrote a blog on steps to take in the event that you received a letter from Medicare or Medicaid for an audit, please click here to read the blog.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.
The Health Law Firm's attorneys routinely represent physicians, optometrists, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.
To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at


As an optometrist, have you run into any of these issues in your practice? Please leave any thoughtful comments below.


John Rumpakis, O.D., OMG! It's MGD!, Review of Optometry, October 15, 2012, at 30.

About the Authors: Dr. Thu Pham, OD, is a law clerk with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area.  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Tag Words:  Optometrist, Medicare fraud, Medicaid, fraud, billing, Medicaid audits, fraudulent billing, recovery actions, Medicare audits, probe audits, Medicare defense attorney, Medicaid defense attorney

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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