Medicare administrative contractors have begun a new type of review focused on preoperative documentation. Following a probe in California, Noridian HealthCare Solutions has expanded its review to the rest of region JF. Physicians in Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming should prepare for review.

How the new preoperative review works

Under the Targeted Probe with Education and Extrapolation, contractors conduct multiple reviews of a practice’s claims. Action depends on whether the practice can reduce claims denials during these reviews.

• Prepayment probe: Practices that get audited go through three rounds of review. If they continue to receive high denials after the first three rounds, the contractor can perform a fourth round that includes a post-payment review with extrapolation.
• Resolution: At the end of each round, physicians receive claims results and education on errors identified. If they have a high error rate, the education will be one-on-one. If you have an acceptable rate, the contractor will remove you from review.
• Failure: Practices that don’t improve their denial rate face extrapolation or referral to Zone Program Integrity Contractor.

As of this date, ophthalmologists in at least 10 states have reported request for records for CPT code 66984 Cataract extraction with IOL.

How to prevent preoperative documentation errors

Here’s what you need to know so that you don’t repeat these errors.

• Signatures: All claims must include legible physician signatures where required and legible. This includes the operative report. If you use electronic health records, the physician signature must be secure.
• Deadlines: Submit documentation within the time frame requested.
• Acuity: Make sure the record includes the patient’s Best Corrected Snellen Visual Acuity.
• Impairment: Document the patient’s reported impairment of visual function resulting in restriction of activities of daily living.
• Informed consent: Document that the patient desires surgical correction and has received an explanation of risks/benefits/alternatives. Document that the expected outcome will significantly improve visual and functional status.

For additional help correctly documenting these procedures, take the Academy’s new e-learning course, Complete Guide to Documenting and Coding Cataract Surgery.