Ophthalmology and Optometry Coding Alert

Question: We brought on a new ophthalmologist who is very interested in medical coding. He started going over some of the other physicians’ codes and found them to be coded inaccurately. He seemed to suggest that the coders should have caught these issues. Is this true? What can we do?

Minnesota Subscriber

Answer: Coders should typically be cross-checking any codes billed against the documentation. If it isn’t in the record, you cannot report the services. If your coding staff hasn’t been doing that, it may be a good time to perform an audit so you can determine whether the codes billed actually match the documentation in the charts.

You can either perform a prospective audit (in which your practice examines new claims before you file them) or a retrospective audit (when your practice examines paid claims). A prospective audit helps you identify and correct problems before sending the claim, which could mean you’ll discover incorrect coding or charges that would otherwise have been missed. Keep in mind that this type of chart audit can potentially delay billing, however.

Retrospective chart audits do not delay billing but cause your office to be reactive by refiling claims, rather than proactive in finding problems before you submit the claims.

Keep in mind that just because documentation supports the level of service billed, the coder or biller must be sure that it’s medically necessary to report that level of service. If an office visit and a procedure are coded, does the documentation support both? Was time a factor in coding the service? In the cases in which counseling and/or coordination of care dominate more than 50 percent of an encounter, time also is considered a key controlling factor in qualifying the visit for a particular level of E/M service, but you must ensure that the documentation supports time-based billing.

Finally, make sure that the diagnosis codes on the billing form are supported by what actually appears in the record. Once you gather all this information, you can provide a report to the entire staff so every clinician is aware of what errors are being made, and then create an audit schedule so you can continue to stay on top of the claims and make sure any issues have been rectified.