Ophthalmology and Optometry Coding Alert

The word “audit” can strike fear in the hearts of coders and compliance professionals, but it doesn’t have to. If you want to confirm that you’re collecting the amounts you should, and that your providers are coding accurately, a self-audit can help ease your mind and show you a full-circle picture of how your practice is doing.

Chart audits are a good way to pick up services that were performed but weren’t billed, and then things that are billed but weren’t properly documented. You may actually rescue some money with audits, and you may also avoid compliance nightmares — but the best part about performing self-audits is that it puts everyone in the office on the same page. You’ll all get a feel for what’s being done properly, what needs work, and how the staff can work together to rectify anything that’s not up to snuff.

What it means: When you perform a self-audit, you’re comparing the codes, billing records, claims, and medical records that your providers recorded to verify expected treatment outcomes and medical necessity of services. In addition, you’ll look for appropriate documentation to support fees and reasonable charges for services your physicians rendered.

Why you audit: When you audit your physician’s services, you can uncover incorrect coding patterns or compliance issues. The plus here is that you’ll discover any problems before an outside auditor (such as one from the OIG or a private insurer) does.

Before you perform your first audit, you should make sure you have current CPT^®, ICD-10-CM, and HCPCS Level II manuals available. And get your most recent National Correct Coding Initiative (NCCI) edits close at hand, along with local medical review policies, E/M guidelines, and a medical dictionary for reference during the audit.

Who should participate: You should involve every member of your practice in your audit. In particular, you’ll want to hold a staff meeting before the audit to explain what you’re doing and why, and to remind staff members that you’re not trying to get anyone in trouble. Instead, you’re hoping to help them figure out what they’re doing right, and determine what they should work to improve that will help the practice ethically bring in more reimbursement and decrease denials.

If your practice has never performed an audit, you should consider the following factors so you can determine how many records to audit:

• Your annual case volume
• The number of providers in your practice
• The number of coders and billers in your practice.

You should audit at least 10 to 15 records per provider if you’re in an outpatient practice, or 5 to 10 percent of the records if you’re at a facility.

If the outcome of your audit shows a compliance rate of 90 percent or above, you should self-audit once a year thereafter. If the outcome shows a compliance rate of 70 to 89 percent, you should perform a repeat audit at six months. If the outcome reveals a compliance rate lower than 70 percent, you should perform repeat audits quarterly until the percentage improves to 90 percent or above.

Examine Documentation for Problems

When you perform the self-audit, you should read the documentation and select which ICD-10-CM and CPT^® codes you think apply to the chart. Then check which codes the physician or coder actually assigned to find out whether they selected the right codes for the services that the physician documented.

Tip: Someone other than the original service provider should review the chart for accuracy, because the audit must be objective.

Combat Problem Areas

Following the audit, you should develop some tools within your practice to make documentation easier. For instance, if your audit reveals that one physician in particular bills all 99213s for office visits, make that physician a card that explains the details of each E/M code, or write up a template that shows them exactly what’s required before they can elevate a code to 99214. Then the provider will be more inclined to select the right code.

Or you might want to make up a list of the top-50 diagnosis codes that your practice reports so the physician can easily reach for the right ICD-10-CM code every time, rather than writing nonspecific diagnosis statements such as “blurred vision,” which often leaves questions about the type of blurred vision or cause.

Hang on to Documentation

You should retain all of the documentation from your self-audits in your office to demonstrate what you reviewed and what you changed. Your records should indicate whether your audit was part of a regular compliance program or whether you performed it because you had a problem and you wanted to use prospective measures to avoid future inaccuracies.