Ophthalmology and Optometry Coding Alert

Protect yourself from carrier audits with these handy tips

Watch out: Carriers are looking over E/M claims more than ever before -- and claims that fall outside the carriers' "bell curve" of typical billing practices are high on their list.

When you report high-level E/M visits, you should look for signs that your carrier's audit staff may find them an attractive target, says Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, a consultant with Medical Professionals Inc. in Indianapolis and president-elect of the AAPC National Advisory Board. Grider has been
working with providers who have been hit with pre-payment E/M audits.
 
Many carriers look for overutilization of the higher E/M levels for new patient, hospital admission or consult services, Grider says.
 
Example: If your physician always reports a level-three (99223) hospital admission, he may be at a higher risk of downcoding and/or audits, Grider says. Look for the warning signs that your E/M claims may appear to be upcoded, she says.
 
Red flag: A physician codes a level-five office consult (99245) with a comprehensive exam and high level of medical decision-making (MDM). But if the physician's history doesn't contain enough detail, the carrier will likely downcode the claim.
 
Similarly, you're risking a downcode for a level-five visit if the history and exam are comprehensive, but the patient only has diabetes symptoms that are mildly exacerbating and the physician only prescribes medication, Grider says.
 
Do this: Make sure your documentation includes "all data relative to the presenting problem," and that the MDM outlines the physician's assessment and plan of care completely, Grider says.
 
Stay off the radar: Carriers look for physicians whose billing patterns are wildly different than others in the same specialty or geographic area, Grider says. They compare your claims to the "bell curve" of average physician E/M billing in your area or specialty.
 
If your pattern is different from the bell curve, it doesn't mean you'll be audited. But it does put you on the carrier's radar, Grider says. You should compare your E/M billing to your carrier's data at least quarterly. And you should compare each individual physician's billing to the average as well, to see if one physician is an "outlier."

If one physician stands out as an E/M high-flyer, review his documentation and make sure it supports the medical necessity for the levels billed. If not, you should help educate this physician on E/M documentation requirements, Grider says.
 
Pay attention: Some codes carry a higher risk of audit than others, Grider says. For example, consultation codes pay more than new or established patient codes, so they're more likely to attract attention. They also carry more documentation requirements, including a written request from the referring physician and a letter from the consulting physician, Grider says.
 
Complaints: Sometimes your patients will complain to the carrier about the level of service your physician reported, which can trigger an audit. Your carrier has an obligation to investigate all patient complaints.
 
You should make sure to communicate clearly with your patients about services and procedures to reduce the chances of such complaints, Grider says.