Coding and audits

Coding and audits

Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., Rebecca Wartman, O.D.

Anyone who has experienced an audit understands that the review process can be stressful and time-consuming. While many doctors naturally have concerns about the potential for an audit, it's important that the fear of raising a red ­flag doesn't result in coding that is potentially inaccurate. While there are many coding and billing experts who will try to sell services based on how they can help you avoid an audit, the Centers for Medicare & Medicaid Services (CMS) provide the best guidance:

Maintain accurate and complete medical records and documentation of the services you provide, and ensure your documentation supports submitted claims for payment ... good documentation helps address any challenges raised about the integrity of your claims. You may have heard the saying regarding malpractice litigation: "If you didn't document it, it's the same as if you didn't do it." The same can be said for Medicare billing.


CMS provides examples of improper claims, including:

  • billing for medically unnecessary services
  • billing for services not provided
  • billing for services performed by an improperly supervised or unqualified employee
  • billing for services performed by an employee excluded from participation in the federal health care programs
  • billing for services of such low quality that they are virtually worthless
  • billing separately for services already included in a global fee, like billing for an evaluation and management service the day after surgery

When it comes to optometry, questions are often raised regarding whether it is preferable to report the 99xxx evaluation and management codes for office visits or to bill the 92xxx ophthalmologic examination codes. Some doctors worry that billing one code set over the other could trigger an audit. While many want a simple, straightforward answer to this question, the answer can really only be provided by the doctor providing care to the patient. The clinical needs of the patient and the care provided drives the selection of the most appropriate code reported. If you feel the care provided could be reported by either an E/M 99xxx code or a 92xxx code, you will need to use your best judgment and fully document your choice according to the rules of the coding scheme selected. If your coding decision is well supported by patient documentation, you should be able to stand up to any review.

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February 6, 2019

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