Ophthalmology and Optometry Coding Alert

Eye care coders who have never performed a self-audit may wonder whether they have what it takes to complete the audit. But if you tick a few simple options off of our checklist, you’ll be on the right track.

If you don’t know quite where to begin when you perform your first self-audit, keep this handy reference with you as a guide to remind you what types of questions you should be asking yourself. For each chart, make sure you can answer the following questions, and you’ll know you’ve done a thorough job:

Audit Checklist

• Does the documentation in the chart support the level of E/M service that the physician billed?
• Does the documentation in the chart support the codes for non-E/M services, such as procedures or diagnostic tests, that the physician billed?
• Did the physician use modifiers correctly?
• Does the physician’s documentation support the ICD-10 codes the practice reported?
• Did the providers date all entries?
• Is the chart legible?
• Are the names and identification numbers of the patient and provider on each page of the claim form?
• Does the patient identification sheet include completed biographical data, including the patient’s address, employer, home and work telephone numbers, and marital status?