By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement
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How often do cataract surgery charts fail an auditor’s scrutiny? Far too often, according to a national audit that was performed by Noridian in its capacity as the CMS national Supplemental Medical Review Contractor (SMRC).1
An Error Rate of 51%!
When the SMRC requested cataract surgery charts from 2019 to see if they established medical necessity, the error rate was 51%. This was, unfortunately, consistent with Targeted Probe and Educate (TPE) results highlighted in “Auditproof Your Evaluations for Cataract Surgery” (Savvy Coder, October 2022). In reviewing its findings, the SMRC highlighted three common problems that caused failed audits.1
Problem—no response to the documentation request. Many practices didn’t respond to the SMRC’s request for documentation by the auditor’s deadline, with some not responding at all.
Solution—look for the bright green envelope and establish a protocol. If Noridian includes you in an SMRC audit, it will send you the additional documentation request (ADR) in a bright green envelope. There is a deadline for returning the required documents, so you will need to respond promptly.
It helps if you have policies in place ahead of time. Designate a point person who will be responsible for any ADR. Make sure staff and physicians know that any audit requests should immediately be forwarded to that point person or, in case of their absence, a designated backup. Once your practice receives the green envelope, all physicians and administrators should be alerted about the audit.
(Warning: faxing documents to the SMRC isn’t always a reliable option, according to some of your peers who failed audits due to nonreceipt of their attempted submissions.)
Problem—insufficient documentation. Incomplete documentation resulted in many audit errors.
Solution—know the documentation requirements. Medicare Administrative Contractors (MACs) publish local coverage determinations (LCDs) and articles (LCAs) that provide specific guidance for documenting the medical necessity for cataract surgery (aao.org/ lcds). You can make sure your documentation is sufficient if you abide by this guidance and use the Academy’s resources, which include internal audit tools. Additionally, the AAOE has created the online Cataract Surgery Documentation Hub to catalog resources, checklists, and urgent updates for cataract surgeons and their staff to ensure documentation meets the payer standards. Academy and AAOE members can access this resource.
Problem—failure to meet signature requirements. Some charts didn’t include a signed physician order for cataract surgery or documentation that supported the intent to order the procedure. Problems included paper records that didn’t meet the payer’s signature requirements and unsigned documents that had been scanned into the EHR. (EHR documentation can also be noncompliant when you “clone” operative reports or written orders.)
Solution—understand the signature criteria. CMS has published Complying With Medicare Signature Requirements, an MLN Fact Sheet that outlines how to meet the signature criteria.2 Also review the AAOE’s guidance, which is available at aao.org/coding (scroll down to “Coding Topics” and click “Signature Requirements”).
Be ready for increased scrutiny. As high audit error rates for cataract surgery continue, ophthalmology must anticipate additional reviews that are more serious and frequent. Additionally, with the increase of prior authorization requirements, insurance payers may add even more scrutiny when seeing a 50% failure rate for charts. The Academy is committed to ensuring access to care, and this includes helping practices to improve chart documentation of these services.
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More at the Mid-Year Forum. If you are attending the Mid-Year Forum (MYF), you won’t want to miss Hearing 1B: Prior Authorization, Audits, and Documentation (Friday, April 21, 8:15-9:45 a.m.), moderated by David Glasser, MD. Register at aao.org/myf.
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1 https://noridiansmrc.com/completed-projects/01-302/. Accessed Dec. 29, 2022.
2 www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf. Accessed Dec. 30, 2022.
Get Help Checking Your Charts
Would your practice’s documentation of cataract surgery and/or intravitreal injections survive an auditor’s scrutiny? Visit aao.org/consulting for consulting services that can help you conduct an internal audit.
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