Optometry Coding & Billing Alert

Question: Our Medicare carrier is doing a lot of prospective audits. How can we respond in the most compliant way possible when the carrier comes for us? How can we also learn from the auditing process?


Massachusetts Subscriber

Answer: When Medicare's bell tolls for your office, you want to keep good records of its audit so you can learn from it. Keep a log of Medicare's requests, the date you received them, the doctors, patients- names, what codes you reported, and what responses you sent to Medicare.

Make sure the responses aren't sent out by just anyone. The optometrist and the manager in your office should review all of the information before you respond to Medicare's request.

Ensure that what you send them is legible. If you fax the notes to Medicare, the reviewers may not be able to read the copy.

Every month, go back through your log and see what Medicare has paid you and what it denied--and then learn from the audit.
 
Caution: The only way you-ll find out what Medicare will end up paying you after the audit is to look out for what it sends you. The audited claim won't be highlighted; Medicare will just pay it out, lower the code, or deny it, depending on how they assess your documentation. Medicare's request is the only measurement that tells you Medicare's -opinion- of your documentation. If Medicare downcodes your claim, figure out why, and audit the claim yourself to see if you agree.

Opportunity: Teach staff what you-ve learned from the Medicare providers. Show them Medicare's changed claim, saying, -This is the one that we billed as a 99213, and Medicare audited it as 99212. We agree with Medicare because of these components. So, from now on, if this is the level of service we provide and document, use code 99212 for appropriate billing.- Or, -This is a claim that was coded as a 99213, and it's paid as a 99213. So, we-re on the right track.-

Experts say: Always question rule violations you don't understand. Medicare auditors read the same vague rules and LCDs that coders and billers read.

Don't be afraid to ask to see a rule in writing on anything you don't agree with.