Put on Your Audit Armor, Part 1

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It’s not a matter of if but when a third-party payer sends you a request for records. And when that day ar­rives, having a written protocol in place will help to ease your angst. Here’s how to get started.

Be Audit Ready: Create Written Protocol

Use the protocol below as a starting point, and customize it to fit your practice.

You receive a request for records. What do you do next?

1. Do not toss the envelope. It shows the postmark date. The letter inside may be dated much earlier than the date when you received the request.

2. Determine the type of audit or investigation. The government has assigned auditing duties to several types of organization, each with its own type of audit. These include the following:

• CERT: Comprehensive Error Rate Testing
• OIG: Office of Inspector General investigation
• RA and RAC: Recovery Audit (RA) and Recovery Audit Contractor (RAC)
• SMRC: Supplemental Medical Re­view Contractor
• TPE: Targeted Probe and Educate
• ZPIC: Zone Program Integrity Contractor

The mechanics of the audit may vary, depending on which type of audit is performed.

3. Identify the due date for sending records. Respond within the time limits provided, or immediately request an extension. Make sure you document written confirmation of new due date.

4. Look for the common theme. Does the auditor seem to be zeroing in on a particular level of E&M or Eye visit code? A consistent modifier? A particular testing service? A high-volume surgery? Is it a single date of service versus a series of encounters?

5. Note the date of service request­ed. Make sure that you are gathering documentation for the correct date of service.

6. Check the records for signatures. For paper charts, is the physician signa­ture present and identifiable? If signatures are illegible, immediately prepare a signature log. Include the names of all who document in the medical record and identify their title (i.e., MD, DO, OD, technician, scribe, receptionist, etc.). If the signature is missing from the medical documentation, it is acceptable for the author of the medical record entry to add a signed attestation that he or she had entered the original information into the record.

If you use electronic health records (EHRs), provide documentation that the physician signature is “secure” and nobody else has or uses the physician password. Most audits also request EHR signature protocol. Without an identifiable, secure physician signature, the auditors do not have to complete the actual audit—they can just deny payment.

7. Provide a list of abbreviations used. Don’t assume that the auditor will understand the abbreviations used in your records.

8. Check whether LCD(s) apply. If the payer has a Local Coverage Deter­mination (LCD) on a test or surgery performed, quote chapter and verse from that LCD. Be sure to use the LCD that was in place at the time the test or surgery took place.

9. Make sure tests are fully docu­mented. If testing services are part of the audit, make sure there is a written order that identifies by name what test and which eye(s). Furthermore, the medical necessity for the test should be obvious in the medical record; the phy­sician should provide the interpretation and report as soon as possible; and if the delegated test falls under direct su­pervision, make sure the payer is aware that one of the practice’s physicians was on site during the test.

10. Self-audit. If the auditor is looking at E&M or Eye visit codes, audit internally before submitting the documentation, so you can gauge your worst-case scenario. Next, you can estimate how much money the auditor might seek to recoup and plan accord­ingly.

11. Make sure that a physician re­views the documentation. Physicians should have the opportunity to review all records before that documentation is sent to the auditor.

With paper charts, if the handwrit­ing is not readily legible, physicians should take the time to dictate (not embellish) the notes. Include the actual chart note plus the dictation. After all, only that which can be read can be audited.

With EHR, check whether all fields are populated. For example, if doc­umentation shows only those body systems that have a problem and not those that are normal, you won’t receive credit for reviewing 10 or more systems. Work with the vendor to make sure all fields show when the record is printed.

12. Remember that the Academy is here for you. Email coding@aao.org.