FEAR OF AN AUDIT IS NOT A GOOD STRATEGY; PREPAREDNESS IS

IT IS fair to say that the average physician is totally unprepared when an insurance audit strikes. We fear them, rather than properly putting in place processes that will allow us to deal with them as a normal part of business. Health care audits are an integral part of the quality control cycle for all health care stakeholders; the federal and state governments, third party insurers, healthcare providers, and patients.

Fraud, waste and abuse all have different definitions and implications in any audit. It is important to understand the differences and ramifications of all three as they apply to your practice. In my role on medical management committees of carriers and aiding O.D.s in audit defense, optometry has the highest exposure in the following three areas:

1. Lack of medical necessity noted in record
   a) For the specific type and level of office visit coded
   b) For special ophthalmic procedures performed
2. Improper coding of office visits
   a) Overuse of 920X4 codes
   b) Improper use of 92012 codes
   c) Improper coding of 992XX codes — approximating the level rather than actually coding correctly
3. Improper use of modifiers -25 and -59

CMS has consolidated all of its fraud and abuse products into its Medicare Learning Network. (Access it at http://go.cms.gov/2tRZDyW .) These resources can help practitioners identify “red flags.”

BE AWARE

As eye care practitioners, we tend to overutilize diagnostic testing without properly noting the need for the test. Remember that in most cases, once a diagnosis has been reached, additional testing cannot be done just to confirm or to embellish the medical record. Thus, instrumentation that provides the same diagnostic clinical data should not all be used on the patient. The principle should be applied to the category of and the level of the office visit performed. The minimum level of service to properly diagnose and provide treatment for the patient is generally the most appropriate, not a higher level just to enhance revenues or because a patient has a specific ICD-10.

When it comes to using modifiers, please understand the definition and proper application of a modifier before employing it.

BE KNOWLEDGEABLE

The law requires you to know the rules of the CPT and ICD; you also must have knowledge of carrier policies, which you agreed to when you became a participating party. Understand these rules and execute them with precision and you will generally come out of the audit process well. The problem, of course, is feeling that the rules don’t apply to you or that your practice is an exception.

BE PREPARED

The question of when — not if — is the critical part of this article. Remember that an audit is nothing more than a system of checks and balances. The carrier paid you in good faith based upon the claim you submitted; an audit is simply making sure that the medical record supports the codes used on the claim form.

Learning how to be properly prepared for an audit is not an event, but a daily process of providing only the care that the patient requires, creating good medical records that properly reflect the encounter and translating, accurately, the medical record into the appropriate CPT and ICD-10 codes. Master this concept and the anxiety of an audit will be something of the past, not to be feared in the future. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com.