Medicare Overpaid Optometrists for Nursing Home Visits. In OIG's Sample, Not One High-Level Visit Held Up.

On October 15, 2026, CMS put a short compliance item in its MLN Connects newsletter: optometry services at nursing facilities, bill correctly. It points to an audit by the HHS Office of Inspector General (OIG), and the audit's numbers explain why CMS is repeating it.

OIG looked at Medicare Part B payments to optometrists for the two highest levels of subsequent nursing facility visits, CPT codes 99309 and 99310, from 2021 through 2023. In that period Medicare paid $4.7 million to 200 optometrists for these codes. Fifteen of them received 72 percent of the money. OIG sampled 225 of their patients and reviewed every one of the 399 high-level visit lines billed for them. None met Medicare's requirements.

What the auditors found in the records

For 395 of the 399 lines, the medical record did not support the level billed. For the other four, the optometrist's office said it did not keep records, and the nursing facility could not produce any either. OIG estimated that Medicare overpaid the 15 optometrists at least $3,059,204.

• Most records showed a chief complaint of dry or itchy eyes, treated with eye drops and a follow-up in a few months.
• Some records showed blurry vision or a follow-up on cataract growth.
• None described a patient who was unstable or needed immediate attention. The records showed that the patient needed an eye exam.
• Some showed that the facility had asked for the visit weeks or months earlier, which OIG read as a routine visit, not an urgent one.
• None recorded how many minutes the optometrist spent with the patient.

OIG also noted that from 2023 the AMA guidance for these nursing facility codes raised the time thresholds, to 30 minutes for 99309 and 45 minutes for 99310, and tied the code family to patients with multiple conditions that need active management.

What CMS agreed to do

CMS agreed to have its contractors review a sample of the 15 optometrists' claims and recover overpayments that fall inside Medicare's 4-year reopening window. It also agreed to share the audit with its contractors for their risk analysis and work planning, and to provide education on billing optometry services in nursing facilities.

CMS did not agree to add national system edits or to increase claim reviews, saying its contractors must put limited resources where the impact is largest. OIG reported that CMS has no national edit limiting which E/M codes optometrists can bill, but two Medicare Administrative Contractors have built their own. So whether a high-level claim from an optometrist pays today can depend on which MAC processes it, and a claim that pays is not proof it was billed correctly.

Why this reaches beyond the 15 optometrists

The audit named no practices publicly, and CMS's recovery covers only the 15 selected optometrists. But the other 185 optometrists who billed these codes received about $1.3 million in the same period, and CMS has now told its contractors where to look. The pattern OIG described, a routine eye visit billed at the level meant for a complex, unstable patient, is easy to find in claims data.

Medicare Part B does cover real eye care in nursing facilities. CMS's Vision Services booklet lists eye exams for patients with diabetes, diagnostic tests and treatment for age-related macular degeneration, and an annual glaucoma screening for patients in a high-risk group, billed with G0117 or G0118 and diagnosis Z13.5, with the risk group documented in the record. Original Medicare does not cover routine eye exams. The risk is not in the visit. It is in the code chosen to bill it.

A check to run this month

This is general information, not legal or coding advice for your practice. An eye-care practice that sends optometrists into nursing facilities can start here:

• Pull every Medicare claim since October 2022 with place of service 31 or 32 billed by your optometrists, and count the visits by code and level.
• If most nursing facility visits are billed at the two highest levels, treat that as a flag and review a sample of records against the code requirements.
• For each visit in the sample, check that the record shows why the visit happened, what problem was managed, how complex it was, and the total time when the level was chosen by time.
• Ask your coder whether the eye exam codes, rather than nursing facility E/M codes, describe what your optometrists actually do on a routine facility visit.
• Keep your own copy of every facility visit note. Do not rely on the nursing facility to produce it later.
• For glaucoma screenings, confirm the patient's high-risk group is written in the record before billing G0117 or G0118.
• If the review finds claims that should not have been paid, talk to your compliance adviser about returning them. Medicare has deadlines for reporting overpayments once they are identified.

A practice that reviews its own claims first can fix the pattern and return what it owes on its own terms. A practice that waits for a contractor's request may be answering for four years of claims at once.

The level is the claim

In this audit, the eye care was real. The overpayment came from the level billed. VOSKPO helps practices check E/M level patterns against their documentation before an auditor does. A revenue review can show where your coding pattern stands out.