Coding Q&A

EMR, retina diagnostic testing and Medicare audits


EMR, Retina Diagnostic Testing and Medicare Audits

Information Provided by Riva Lee Asbell

This month's column focuses on EMR issues involving diagnostic tests used in the retina practice. Flaws and omissions in some EMR programs may trigger Medicare audits.

EMR Issues. Since many practices have incorporated EMR, there have been some interesting developments from the perspective of Medicare audits. For 10 years, the Practice Management Committee of The American Society of Cataract and Refractive Surgery sponsored an EMR standoff wherein different vendors were given clinical scenarios to document as the audience watched them being projected on large screens. In the Q&A session that followed, compliance and coding issues were evaluated. One of the main problems that recurred the entire time, for every vendor, was the lack of a proper Interpretation and Report for each diagnostic test.

Interpretation and Report Requirements. This subject has been covered extensively in two articles that are available under Articles/Retina and Articles/Diagnostic Tests at Essentially, the "Three Cs" need to be addressed in separate documentation: clinical diagnosis, comparative data and, most importantly, the clinical management. The clinical management should also appear in your Impression/Plan.

In computer-generated reports, I have never found the clinical management addressed. I urge you to add it to computer-generated reports — it must be addressed. Most hard-copy charts, even with dictated letters, fail to fulfill this requirement as well.

Extended Ophthalmoscopy: Drawing Requirements. This varies with each contractor/carrier. Empire's is among the more stringent. Follow the guidelines below and you will never be faulted. Without the proper drawing, your claim will be denied because it will be considered merely part of the general examination. If your drawing is considered a sketch without enough detail, you will be denied and repay under audit, possibly with penalties.

► Diameter: 3 to 4 inches.
► All items must be identified and labeled.
► Colors: 4 to 6 standard colors, although clearly labeled non-colored drawings are acceptable. The drawing should be anatomically specific to that patient and should represent normal, abnormal and common findings (eg, retinal detachments, hypertensive changes, proliferative diabetic retinopathy, lattice degeneration).

Several of the requirements are quite obviously not met in an EMR drawing, the most obvious being it is not anatomically specific and detailed, but usually a mere sketch. Moreover, the drawing is seldom labeled.

Tips. With an EMR-generated medical record, there is complete legibility, making omissions and mistakes glaringly apparent. An auditor can now easily determine who did what, what was done, what wasn't done and how well it was done. Here are some tips for ascertaining that your EMR chart notes are in order when your records are requested by any of the auditing agencies for Medicare. Personally review beforehand what is being sent.

► The order for each diagnostic test must be entered in the medical record.
► A copy of the test images must be included.
► Include a print-out of the extended ophthalmoscopy drawing.
► The Interpretation and Report must be entered into the medical record and included in the printout. With digital imaging that may have been read at a remote site and not during the patient encounter, the I&R may not be entered into the EMR but incorporated into the separate imaging system's data.
► Signature issues are among the hottest ticket item in Medicare's audits today. Absolutely make sure that the test is signed electronically. Keep up-to-date on electronic signature requirements. RP

CPT codes ©2010 American Medical Association.

Riva Lee Asbell can be contacted at, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.