Ophthalmology and Optometry Coding Alert

Regardless of which auditing model your practice decides to adopt, it’s a good idea to start by reviewing 10 claims per provider every quarter. Whoever oversees or manages the review for that particular day should make sure all the information is available for the review, which can include the following:

• The patient list from the appointment schedule that day
• Encounter forms/surgical report
• The claim with the codes that the provider selected

Then the reviewer will scrutinize things like:

• Level of E/M services or eye codes reported
• Duplicate billing
• Billing for services that weren’t actually performed based on the documentation
• The use of modifiers, which escape most claim editing systems
• Whether services match the date you bill them
• That supporting documentation is in the record
• That diagnosis codes match up with the encounter form
• Provider signature verification

When the auditor is checking codes and bills against documentation, they should check whether your office missed billing some services that were performed and documented, check documentation of the services rendered, and substantiate the codes that were charged. Also, auditors should check to see if ancillary services that were performed were billed and not just waived.

When the review is complete, it would help the providers if your auditor showed them how they compare to other providers. Comparison may help convince the providers to change their coding processes. The auditor can present to each provider a printout of the normal distribution of E/M codes and E/M codes in the specialty of eye care. You could also show distributions of other procedure to see where your provider falls within the range of coding, according to national standards.