A recent audit of physician records shows three common documentation errors. Audits under the Comprehensive Error Rate Testing program revealed the following errors in chart documentation:

• Documentation lacks chief complaint;
• Documentation lacks history component;
• Comprehensive exam billed when less than 12 elements of the exam are documented and mental assessment missing.
• Missing or illegible signatures continue to be one of the top reasons for claim recoupment and denials. If necessary, provide an attestation and typed transcription of the charts requested for review to ensure the auditor captures all data.

Improve your chart documentation with the following tips:

• Consider medical decision making as the highest factor when submitting an E&M code;
• Reminder: Both over-coding and under-coding are considered billing errors;
• When ordering testing services, be sure to state the specific test rather than a generic statement that a test is ordered. Auditors also expect to see documentation of which eye or eyes should be tested;
• Don’t forget the interpretation and report.

CERT audits Medicare Administrative Contractors by evaluating physicians’ records. CERT confirmed that each MAC reviewed is following its local determination policies and Medicare Part B guidelines.

Learn more about chart documentation in Ophthalmic Coding: Learn to Code the Essentials and the Learn to Bill page in the Young Ophthalmologist section.