Conducting audits and chart reviews in house can safeguard your practice and help ensure that you are billing correctly. Although the process might seem difficult, there’s nothing an outside auditor can do that you can’t do yourself. Here’s how to perform your own internal audit the way the payers do.
Getting Started
Any basic audit starts with pulling some reports. An internal audit works the same way.
- Run a productivity report for each physician in the practice.
- For each report, identify the E&M new patient/established patient or Eye visit new patient/established patient services with the greatest volume. (Remember: Audits will likely focus on those services for which you have the highest volume.)
- Once you identify the codes to review, pull a sampling of charts for that provider — as few or as many as you’d like.
- Review the documentation for each visit to check what level you should have submitted to the payer.
- Compare the correct level to the level actually billed.
- Address any areas of concern immediately. These could include:
- Billing a higher or lower level of service than your review shows;
- A missing physician signature;
- Missing orders for testing services;
- Consistently missing data that could change the level of code, etc.
- Re-educate as necessary.
The example below will guide you to determine the correct level of E&M or Eye visit code.
Sample Audit
Chief complaint: Failed vision screening with eyes turning inward.
History: A three-year-old girl has a one-year history of her left eye crossing in. Her parents have noticed that the crossing occurs more often when she is tired and seems to have worsened over the past six months. She failed her vision screening during her primary care exam, which showed anisometropia with left hyperopia greater than right hyperopia. Otherwise, the patient demonstrates good visual behavior.
Review of systems: The patient’s family filled out the form. The physician reviewed the ten systems and listed all as negative except for the eyes, and signed off.
Past, family and social history: The patient — a preschooler — is healthy otherwise and is using no medications. There is no family history of any eye disease or problems.
The history documented in this chart is comprehensive for an E&M service and Eye visit code. Comprehensive history is determined by an extended history of present illness, complete review of systems and complete past, family and social histories.
Exam: The physician documented 11 exam elements after dilating the pupils and did not include an IOP or mental assessment. S/he documented the refraction with this final prescription:
| |
Sphere
|
Cylinder
|
Axis
|
|
OD
|
+5.00
|
+0.50
|
90
|
|
OS
|
+7.00
|
+0.50
|
90
|
For E&M codes, 11 elements qualifies as a detailed exam. For Eye visit codes, you should consider this an intermediate exam; a comprehensive exam requires 12 exam elements. Remember, if you cannot perform the element due to contraindication or poor cooperation from the patient, the documentation should state this in order to count.
Medical decision-making: The physician decided to prescribe the cycloplegic refraction for full-time wear and recheck the alignment and vision with correction. The physician discussed this assessment and plan with the patient and family and answered their questions. The patient is to return in three months. The diagnoses for the exam were:
Accommodative esotropia: H50.43
High hyperopia LT > RT: H50.22, H50.21
Anisometropia: H52.31
Amblyopia suspect LT: H53.042
To decide on the level of medical decision-making, consider the following:
- Problem category: Extensive — this is a new problem with workup.
- Type of data: Minimal — only the refraction was ordered.
- Table of risk: Low risk.
The determination is therefore low medical decision-making for E&M service. For an Eye visit, the physician performed a refraction and scheduled a follow-up for three months, which constitutes the initiation of a treatment program.
Audit Results
This audit shows a comprehensive history, detailed exam and low medical decision-making: E&M level 99203 or intermediate Eye visit code 92002.
- If you billed that to the payer, this chart would pass an audit.
- If you didn’t bill the payer correctly, use the discrepancy as a training tool for staff and physicians.
In addition to checking correctness of billing, remember to check your payer’s allowables; they can differ. For example, a Medicaid plan allows $27 for 92002, whereas it allows $58 for 99203. A commercial payer, on the other hand, allows $79 for 92002 and $89 for 99203. Since ophthalmologists have two exam codes to choose from, bill the one that pays the most.
Although Medicare often has a higher allowable for established Eye visit codes, commercial payers do reimburse differently. They also limit how often you can submit an Eye visit code. Always follow your payer’s guidelines.
Additional Resources
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.