Practices are reporting chart audits from StrategicHealthSolutions that involve anywhere from 1 to 50 records. Some have a common denominator such as a level of exam, a particular modifier, or a test. Some are an assortment of all the above. Here’s what you need to know about these audits.

1. Know who’s auditing you: StrategicHealthSolutions performs Supplemental Medical Review Contractor audits on behalf of Medicare Administrative Contractors. These are not OIG audits. The $22 million potentially inappropriate payments in 2012 occurred in part due to MACs not setting up denial fields the way they should have.
2. Provide signed records or a signature log. When you pull the records, an identifiable physician signature is of most importance. If you don't have the physician's signature, be sure to include a signature log. For electronic health records, you must obtain an electronic signature. The physician's signature must be secure, meaning the physician doesn't use anyone else's login and no one knows the physician's password. See the Practice Forms Library for sample signature protocols for EHR/paper records.
3. Always include medical necessity. Any delegated test requires documentation of the delegation, including the specific test and which eye(s). Make sure the chart note reflects the medical necessity for the test and the interpretation and report. Often a previous chart note includes the order delegating the test.
4. Ask for more time when you need it. If you can’t collect the information by the due date, promptly ask for an extension.
5. Note the applicable Local Coverage Determination. For blepharoplasties and testing services policies, visit Coding Updates and Resources. Be sure to reference the LCD in place at the time of service, which may not be the most recent.