Every Nursing-Home Eye Claim OIG Checked Failed
Summary
For 2021 through 2023, Medicare paid $4.7 million to 200 optometrists for the highest-complexity billing codes covering nursing-home eye visits. HHS's inspector general sampled every claim the 15 biggest billers submitted for 225 residents and found all of it -- 399 lines of service -- failed to meet Medicare's own documentation rules, an estimated $3 million overpaid. CMS agreed to recover the money. It declined to build the system check that would stop it happening again.
E/M -- evaluation and management -- codes are how Medicare prices a visit by how complex it was, not by which specialty billed it. CPT 99309 and 99310 require a significant complication, an unstable patient, or a problem serious enough to need immediate physician attention, plus a detailed-to-comprehensive exam and 25 to 35 minutes with the patient. Most of the medical records actually reviewed told a different story: a chief complaint of dry or itchy eyes, treated with drops, with a follow-up scheduled months out -- a routine visit, billed at the rate for an emergency one.
A 100 percent failure rate, and one office with no records at all
Of the 399 mis-billed lines, 395 -- totaling $34,841 -- had medical records that simply didn't support the code billed. The remaining four, worth $329, had no records to check: one optometrist's office told it doesn't retain patient files, and the nursing facility where the visits happened couldn't produce anything either. Medicare paid all four claims anyway. Across the full $35,729 in sampled billing, found $35,170 -- 98 percent -- was an overpayment.
View data as table
| Records didn't support the code billed | 34,841 | 395 of 399 E/M lines -- documentation showed routine care, not the unstable-patient criteria CPT 99309/99310 require |
|---|---|---|
| No medical records existed at all | 329 | 4 lines of service for one optometrist, who told OIG the practice does not retain records -- Medicare paid anyway |
| Not flagged as noncompliant | 559 | the 15 imaging lines in the sample, which were not part of OIG's E/M finding |
CMS agreed the money was wrong. It won't build the fix.
Scaling the sample across the audit period, estimated Medicare overpaid the 15 optometrists at least $3,059,204⧉ -- roughly 87 times the dollar amount actually confirmed in the sample itself. , Medicare's administrator, concurred with recovering whatever portion of that falls inside the program's four-year reopening window, and agreed to have its contractors tell the 15 optometrists to audit their own billing. What didn't agree to: reviewing more of these claims going forward, or building a system edit -- an automated check inside the claims-processing pipeline -- that would catch the same pattern before it pays out. Two of 's seven claims contractors already run their own edits on optometrist billing; declined to require the other five to do the same, telling its contractors have to spend their limited resources on 'areas with the biggest impact on the Medicare trust fund.'
pushed back in the report itself, noting the 15 flagged optometrists represented 72 percent of the nation's spending on these codes and that had already confirmed the documentation behind every sampled payment was wrong. The agency's only public follow-through so far is a Medicare Learning Network bulletin⧉ published February 12, 2026, reminding optometrists what the codes require. It is guidance, not a gate -- nothing in Medicare's claims-processing system stops the next high-level bill from clearing before anyone checks it.
's $3,059,204 figure is the conservative lower bound of a 90-percent confidence interval from its statistical sample -- the point estimate is $3,272,823, the upper bound $3,486,443 -- and it is what 's own recommendation asks to recover. The estimate covers only the 15 optometrists selected because they billed the most -- the report doesn't say what share of the other 185 optometrists' remaining payments would also fail review, only that they billed far less of the total. does not name the 15 optometrists or say which states the flagged visits occurred in.
- 's inspector general sampled 399 high-complexity nursing-home eye-exam claims from Medicare's 15 biggest optometrist billers and found all 399 failed the agency's documentation or coding requirements.
- The estimated national overpayment is at least $3,059,204 -- against $4.7 million Medicare paid 200 optometrists nationwide for the same codes, with the 15 flagged optometrists collecting 72 percent of it.
- Most flagged claims were billed as complex, urgent visits; the underlying records mostly showed routine dry- or itchy-eye complaints with a follow-up scheduled months later.
- concurred with recovering the money and warning the 15 optometrists, but declined 's recommendation to increase claim reviews or add a system edit that would prevent the same billing pattern going forward.
Sources(2) ▾
- U.S. Department of Health and Human Services, Office of Inspector General, Office of Audit Services, Medicare Improperly Paid Selected Optometrists for Services Provided to Enrollees at Nursing Facilities (A-05-24-00009) (2025-12-01) — 's audit of the 15 optometrists nationwide who billed Medicare the most for high-complexity (CPT 99309/99310) subsequent nursing-facility E/M visits, 2021-2023. Supplies the $4.7 million national payment total and 72 percent concentration (p.1), the audit methodology and stratified sample of 225 enrollees / 414 lines of service (p.5, Appendix A), the finding that all 225 sampled enrollees and all 399 E/M lines failed Medicare requirements (pp.5-7), the $35,170-of-$35,729 sample overpayment split between documentation gaps ($34,841 / 395 lines) and missing records entirely ($329 / 4 lines) (p.6-7), the $3,059,204 national overpayment estimate (p.7, footnote 18), the three recommendations and 's partial non-concurrence (pp.8-9), and the CPT code complexity table (Table 1, p.3). oig.hhs.gov · original document
- Centers for Medicare & Medicaid Services, Medicare Learning Network, Optometry Services at Nursing Facilities: Bill Correctly (2026-02-12) — 's own provider bulletin, published February 12, 2026 -- two months after the audit -- citing the 's findings and instructing optometrists on the moderate-to-high-complexity billing criteria for nursing-facility E/M codes. This is the training step committed to; it contains no claims-processing edit and no expanded review requirement. cms.gov · original document
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For 2021 through 2023, Medicare paid $4.7 million to 200 optometrists nationwide for CPT codes 99309 and 99310 -- the two highest-complexity billing codes for a nursing-home follow-up visit, reserved for a patient with a significant complication or an unstable condition requiring immediate attention. Just 15 optometrists collected 72 percent of that money. HHS's inspector general⧉ pulled a stratified sample of 225 of those optometrists' nursing-home patients and checked every claim line billed on their behalf. All 399 of them failed to meet Medicare's documentation or coding requirements.