A Beginner’s Guide to Self Audits for Eye Care Practices

Looking to boost your eye care practice’s performance? Start with self-audits. Regular chart auditing helps you guard against compliance missteps and spot patterns that lead to claims denials and revenue losses.

Despite the many benefits of self-auditing, many practices report they don’t do them often enough. Some confess they don’t do chart audits at all.

Why? Self-audits can be overwhelming—especially as you juggle day-do-day practice operations. You might not know where to begin or what to do. You may be afraid of what you might find.

Here’s how to start a self-auditing program that helps you ensure things go swimmingly at your eye care practice:

Step 1: Test the Waters

Decide what to audit. Your options fall into two general categories—risk and opportunity.

Risk audits help you target and remedy coding and billing patterns that expose your practice to denials or audits from private payers or Medicare contractors.

Sometimes, chart audits help you identify coding and billing patterns causing you to collect less reimbursement than you deserve for services performed. Stumped for ideas? Consider these to start. Are you:

  • Shorting yourself on cataract counseling?
  • Appending modifiers where appropriate and where properly documented to get all you deserve for surgical procedures like strabismus surgery (CPT® codes 67311-67318)?
  • Choosing the optimal eye code vs. E/M code choices?

Step 2: Wade In at the Shallow End

Your self-audit should aim for a clear snapshot of how you’re doing without becoming so overwhelming you get nowhere. That’s why experts recommend that you sample data rather than trying to gather 100 percent of all data connected to your topic.

For example, once you’ve selected an audit topic, you might pull 10 charts per provider or 10 percent of total targeted charts, suggests coding expert Lisa Jensen, MHBL, FACMPE, CPC, of AAPC.

“Too large a sample costs more money and resources without added benefits,” explains Frank Cohen, MPA, MBB in a Practice Management Alert article. “Too small a sample creates too much error and renders the results useless.”

Whatever you do, make sure you pull charts within your target area at random to get a true picture, Cohen stresses. “If I have a database of 10,000 claims and I randomly pull 30 of those claims, every one of those had an equal non-zero opportunity of being selected,” he explains. “The sample I end up with should be non-biased and should be close to representative of the universe.”

Step 3: Should You Pay for a Buddy System?

Good coders and billers conduct peer audits as part of their work. Just make sure that the coder doing the audit isn’t the same coder who coded the services in the first place, Suzan Hauptman, MPM ,CPC, CEMC, CEDC tells Practice Management Alert.

If your staff is too small, too overwhelmed, or too underqualified, consider contracting with an outside auditor who can also educate clinicians and staff if necessary, Hauptman recommends.

Step 4: Everyone into the Pool!

If a chart audit reveals a problem or opportunity, don’t keep it to yourself. The most important part comes next—education and positive change throughout your practice.

If you discover an issue among claims for all clinicians in your practice, prepare a report, as well as a sample of two or three claims that illustrate the problem, Jensen suggests. Sometimes, a simple educational session solves the problem. Other times, you may need to update policies and procedures or tackle a flawed EHR template, she says.

Step 5: Work Out Regularly

Perform self-audits at least yearly, says Hauptman, but you may want to self-audit more often if your practice has introduced new procedures. “If you hire a new physician, audit him or her “after 30 days, and then again after about 90 or 120,” she advises.

Bonus! Risk Audit Topics

  • Percentage of complex cataract surgeries of total cataract surgeries performed—CPT® code 66982. National average is 9 percent.
  • Does your established patient E/M coding have more level-4’s and level-5’s than the national average? If so, does clinical documentation support higher-level E/M coding?
  • Are your CPT® code 92250 (fundus photography) claims properly documented?
  • Glaucoma ICD-10 codes.
  • Lucentis injections more often than 28 days per eye or beyond the maximum annual dosing per eye.
  • Is your clinical documentation complete to support claims for intravitreal injections, AMD testing, complex cataract surgery, or claims with modifier 22, 24, or 25?

Remember, if you find a problem that has led to an overpayment, you must comply with the 60-Day Repayment Rule.

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