APR 29, 2021
Stay Current with Payer Policies
While any service you perform the most may be an audit target, you are most likely to be audited on something that has a published policy. Research each payer to see what they require and ensure your documentation exceeds expectations.
What's Included in Policies:
Most payer documentation requirements include coverage guidelines including medical necessity, utilization information, frequency edits and applicable CPT and diagnosis codes. Each payer, including Medicare Administrative Contractors (MACs) each have their own set of policies that vary. Do not apply one payer's guidelines to all you are contracted with, otherwise services will be denied or recouped. These policies are continually updated so be sure you are using the policy in effect for the date of service performed.
Where can you find these policies?
Commercial payer policies may be available on their website, through their monthly newsletters or e-blasts, however you may have to reach out to your provider representative for assistance. With all payers, once it has been published, they expect you to be informed and comply. Each Medicare Administrative Contractor (MAC) publishes their own policies which can be found on their website and through cms.gov. To alleviate practice time searching through these databases, visit www.aao.org/lcds to find the ophthalmic policies that impact your state and jurisdiction.