Medical record audits: How to prepare

Medical record audits: How to prepare

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

We are all subject to an audit, and that can be very difficult and stressful. The best way to prepare in advance of an audit is to review your medical record-keeping techniques.

Types of audits
The two most common audits for optometry are the Recovery Audit Contractors (RAC) and Comprehensive Error Testing (CERT) audits. The RAC were authorized by The Centers for Medicaid and Medicare Services (CMS) to uncover improper CMS payments to providers. The CERT audit is a more long-standing type of audit doing post-payment review looking for fraud and abuse.

CMS authorized a large increase in RAC audits over the past few years and that is continuing into this year. RAC are designed to protect Medicare by identifying improper payments and referring potential fraud to CMS. A study performed by RAC auditors uncovered improper payments totaling $1.3 billion.

The RAC and CERT audits are not the only sources for an audit in your office. Audits also can be the result of referrals from previous employees, complaints from patients, random draw by a computer system, providers using specific codes in what the payer sees as excess of the norm, and sudden increase in payment to a provider.

What auditors are looking for
Essentially, auditors are looking for medical records that are not sufficiently documented. This includes overcoding or undercoding, unbundling issues, misuse of modifiers, medical necessity and Advanced Beneficiary Notification issues, violations of basic documentation rules (patient IDs, signatures, etc.), performance of a special test without an order in the record, special tests without interpretation and report, and billing for an Evaluation and Management level of code not properly documented. Specific to the general ophthalmologic codes, the auditor often finds fault in the lack of "initiation of diagnostic and treatment program."

You are not required to give the auditor the original medical record. Make copies and keep an accurate accounting of all the medical records that were requested and handed over to the auditor. Do not correct a medical record after it was requested; instead, add an addendum to the record when noting discrepancies.

Certain record-keeping items can help you immensely in an audit. Ask yourself:

  • Do the examination notes support the diagnosis?

  • Are the records signed?

  • Are there examination notes for each visit billed to the payer?

  • Did the special tests ordered have support in the medical record, and was an order written?

  • And if a referral was made, was it documented in the record?

If you are chosen for an audit, refer to these tips, seek advice from an expert in audits and/or your attorney, if necessary, and try to keep calm and clear-headed.

September 22, 2014

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