Coding Q & A


It’s Audit Prevention Time: Strong Documentation Is the Key


I had just finished a webinar on the various types of audits when my favorite editor contacted me to let me know my column was due. In the past few weeks, I have begun working with three different law firms on physician audit defense — with two of the three being retina practices.

So this month we are going to review some of the audit prevention measures you can take. The government audit environment has intensified and no practice is immune.


These audits are based on the NCD (National Coverage Determination) that requires a fluorescein angiography before performing ophthalmic photodynamic therapy (OPT).This is the term CMS uses for what most ophthalmologists refer to as PDT (photodynamic therapy).

The audits are supposed to be halted until a the NCD is revised to include the option of having performed OCT or fluorescein angiography before OPT treatment.


► Read the revised NCD and make sure you are in compliance with it.

► Become more proactive. Comment on the proposed NCD revisions. If you think they are flawed or you have another opinion, let CMS know.

► Practice good chart documentation.

► Develop an op note for all intravitreal injections.

► Keep a permanent log of all medications purchased and include lot identifications given to each patient.


RAC (recovery audits) or automated audits are essentially data-mining audits. However, the data these audits use may be flawed. For example, in the verteporfin (Visudyne, Novartis) audits what is generally agreed to have been an outdated NCD was used.

Lucentis (ranibizumab, Genentech USA) is delivered in a single-use vial. Some physicians have decided to use medication from the same vial on multiple patients. This, however, is strictly forbidden.

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► Be sure you and everyone in your practice only uses drugs for intravitreal injection supplied in a vial labeled as single-use for only one patient.

► Make sure your bills reflect the correct dosage. Do random internal audits yourself. In one such audit I’m aware of, the billing people swore that everything was being filled out correctly, only to find out otherwise in the external audit.

► Keep operative notes, drug inventories and logs as noted above, and make sure to perform a pre-review of any medical records that will be sent to Medicare.


A good paper chart still provides better chart documentation than electronic medical records, as evidenced from my auditing of EMR charts. If you were not well trained in E/M and Eye Code chart documentation requirements, the likelihood of you complying with Medicare guidelines is remote.

The Office of the Inspector General, which provides oversight to CMS has included the following items in its 2013 work plan:

We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments … The frequency of services — particularly for AMD and the use of Lucentis — will be part of the review.

Medicare contractors have noted an increased frequency of medical records with identical documentation across services


► Customize your electronic chart documentation for a given patient with free text data.

► Turn off any pre-population of screens and automatic negative defaults.

► Review each patient entry for errors and revise them. That shows you actually looked at the medical record before signing off on it.

► Take all the steps listed above. They should serve you well. RP

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