• How to Prepare for a Medical Record Review

    Requests for records by third-party payers have become a daily occurrence, with seemingly no end in sight. At the moment, practices mostly endure post-payment audits, but some have also received prepayment reviews — and more and more payers are jumping onboard.  

    The process of a medical record review can disrupt a practice and add new burdens. To mitigate this, you should develop a plan of action and thoroughly prepare ahead of time. Here are five tips on how to prepare for the record-review process and conquer areas of vulnerability beforehand.

    1. Plan for appropriate staff communication and review.  

    No records should ever leave the office without appropriate review. Make sure your staff knows that you must be notified and involved. Staff may try to protect their physicians, but you are ultimately responsible for the documentation.

    Before sending information to the payer, you should review the request and documentation fully to confirm that what they requested is actually available. Staff may forget to include previously referenced notes, or they might include only the interpretation of the test, rather than the test itself. Physicians typically catch these errors before records are forwarded.

    All requests come via mail and have time restrictions, so you should also develop written protocol and teach staff how to handle these requests. This ensures that payers receive the requested information in a timely manner.

    2. Make sure to include an identifiable physician signature, whether using paper or electronic health records.

    Missing or illegible signatures continue to be one of the top reasons payers recoup claims. If a signature is missing or unreadable, the auditor may move to recoup funds immediately. You must include handwritten or electronic signatures in all exams and procedures as well as any ordered tests or laboratory services. Auditors will not accept stamped signatures.

    Have your practice create a signature log identifying all persons who document any component of the medical record. By providing this log along with the requested documentation, the auditor can clearly identify who is writing in the chart. Remember that physicians and technicians are not the only ones signing the chart; front-desk or billing staff may also be documenting information. Use the chart below as a guideline for your practice. If you’re using an EHR system, the physician’s password must be secure for authentication purposes.

    3. Document any abbreviations used for certain diseases or procedures.

    Although most practices do use standard abbreviations, some practices create unique language to identify diagnoses, procedures, etc. Keep an up-to-date abbreviation key to all such shorthand. Make the key readily available along with the requested records so there is no misunderstanding by the auditor.

    4. Maintain current copies of payer guidelines for testing services or procedures — for all payers.

    Medicare Part B publishes local coverage determination policies for some testing services and surgical procedures. Although these may not list every service an ophthalmologist provides, the payer will expect you to meet their requirements when a policy is in effect. It’s best to have a current copy printed out and available in order to confirm you are meeting the documentation specifications.

    Commercial payers may not follow Medicare’s policies, so remember not to take one payer’s guidelines and apply it to the rest. Many policies are available online. Otherwise, you’ll need to contact your provider representative for guidance.   

    Track any changes and develop a process to communicate and implement them into your practice. This will help keep you compliant. Each time a policy changes, move the prior version to an archived-policies file; chart requests may go back years. You might also consider providing a copy of the applicable policy along with your records, if audited.

    5. Make sure you bill the correct level of exam.

    Submitting the appropriate level of exam continues to be the number one reason for an audit — more so than surgical procedures or tests — and payers state that incorrectly coded exam levels are still a top reason for claim denials.

    Be sure to follow the audit tool when determining the level of E&M code. The Academy’s online tool, E&M Chart Internal Chart Auditor for Ophthalmology, lets you input the elements for each portion of the history, exam and medical decision-making to determine the appropriate level of E&M.

    There is no formal audit tool for the Eye visit codes. However, the Academy’s 2016 Ophthalmic Coding: Learn to Code the Essentials offers a chapter detailing how to determine the level of both E&M and Eye visit codes so that you can choose the correct code the first time.

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    About the author: 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 Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series.