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Review your own records to avoid Medicare paybacks
Also, be sure to use Current Procedural Terminology and the Documentation Guidelines for the Evaluation and Management Services.
I retired from active consulting Jan. 1, 2016, but I do not think I will ever retire from being concerned about eye care, eye care patients, my optometric colleagues and the importance of excellent medical records. Indeed, Medicare would not have been repaid to the tune of $5.6 billion in 2016 if providers totally understood the importance of keeping good records.
As many of you have heard me say (or have read in this publication), the keys to excellent health care and correct billing for that care are simple. Complying with those keys apparently is not. Not complying with those keys can be very expensive.
Customize each exam
What are the keys? First, every health care provider must be totally focused on the needs of the patient at each visit. “Why is the patient in the office today?” is the question that must be asked and answered before the case history begins and certainly before any testing is done. Once that reason is determined, whether it is a “chief complaint” or a “returned to the office at doctor’s request” or a “90-day recall visit for re-evaluation of visual fields and tonometry,” the case history can be customized, the questions can be asked and the answers recorded.
Once the case history is complete, the examination can be customized to meet the needs of patient and doctor at the visit, with the diagnoses and management options determined and recorded following completion of the examination.
Seems simple, doesn’t it? Yet the evidence is clear: based on Medicare audit results and the results of thousands of “friendly proactive audits” in which I have participated over the years, health care providers, including eye doctors, often ask questions and perform examination elements clearly unrelated to the doctor’s or the patient’s needs that day.
Ideal audit outcome
Speaking of simple, let us consider the audit. Any auditor or friendly reviewer worth her/his salt – whether auditing for an internal records review or for Medicare or some other payer – will open the chart, try to identify the reason for visit/chief complaint and go to the end of the chart to identify the diagnoses and management options recorded.
If there is a direct and obvious correlation between the reason and the diagnosis/management options, the auditor will slide into a less aggressive mode. A quick review of the other elements of the case history and examination will probably fit the expected care pattern related to the reason for visit, and all is well. That is an ideal audit/review outcome.
A common, less ideal outcome would be for the reviewer/auditor to pull 10 claims at random, request the charts that relate to those visits and check the chief complaint/reason for visit against the diagnoses and management options and find less-than-obvious connections between the reasons and the diagnoses/management options. That would provide good evidence that the elements included in the case history and the examination were done for reasons other than the needs of the patient and/or the needs of the doctor managing the case.
Questions asked or examination elements completed just to make the record for the visit “fatter” and, therefore, more valuable in coding a visit are quickly identified and are discounted by the reviewer/auditor, resulting in a lower level code. The dollar difference between the code on the claim and the code the auditor assigns adds up as more records are reviewed/audited. It will not take many of those to result in a payback to the insurer of several thousand dollars and, if the poor record keeping is suspected as being intentional, it might even result in penalties or charges of fraud. This is certainly serious.
Review your own records
So, to paraphrase the television credit card commercials, “What’s in your records?” If every visit is carefully designed to match the patient’s needs and your needs in diagnosing and managing the case, you need not fear an audit/review. If you are not sure whether reasons for visit consistently match content of charts and codes chosen to represent the visits on claims, you may be at risk for an ugly and expensive audit.
You do not want to be among the doctors paying dollars back to Medicare and other insurers. If in doubt, it is critical that you act now. Do not put it off. It could cost you a lot of money.
What should you do? I believe the easiest way to know whether your records and your billing are compliant with the national rules and conventions is to perform periodic reviews of your own records. With a little bit of training, all doctors in your practice will be familiar with the logic of good patient care and the rules for good medical record keeping, which in turn translate into accurate choices of codes and bullet-proof claims.
Use CPT, documentation guidelines
It is critical that you have and use Current Procedural Terminology (CPT, American Medical Association), which includes the only nationally accepted definitions for every service you perform, and the Documentation Guidelines for the Evaluation and Management Services (99000 Series visit codes). Both of these documents are available through the American Optometric Association. CPT will cost you a few bucks, but it will be well worth it. The Documentation Guidelines are available as a free download from the AOA or at the Medicare website, cms.gov. Googling works, too.
If you are interested in doing your own internal records reviews (which is recommended by Medicare’s Office of the Inspector General, the very folks that order the Medicare audits), I can provide you with a sample medical records compliance manual and other tools that you may use. I believe a high percentage of health care providers – sadly, including many of our eye care colleagues – have taken no or just minimal steps to ensure that the care they provide matches the needs of each patient or that the claims they submit accurately reflect the care they have provided to each patient. That is a scary thought for me and it should be for you, also.
Thankfully, in the case of medical records audits, just doing the right thing will nearly always stand you well. The most important path to doing the right thing is knowing what the heck the right thing is. As my favorite NFL quarterback often says: “Let’s get after it!”
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- Charles B. Brownlow, OD, is a member of the Primary Care Optometry News Editorial Board and a retired medical records consultant. He can be reached at: brownlowod@gmail.com.
Disclosure: Brownlow is a retired health care consultant.