One of the biggest reasons for failing an insurance audit is not being specific enough when performing services for a patient. A perfect example of this is what many doctors call a “glaucoma check.” I see it in patient records quite frequently when I’m doing an internal audit for a practice. The chief complaint (CC) might say, “Patient returning for glaucoma check,” or sometimes nothing more than “IOP check.”

Simple phrases mean different things to different people. Just what is a “glaucoma check”? To some, it may be only measuring IOP. To others, it’s a dilated evaluation of the optic nerve, a visual field and an OCT of the optic disc. Some may like to include gonioscopy, while others prefer anterior segment OCT.

Because there’s so much variation in services provided, avoid all-purpose phrases in the medical record. Rather, describe exactly why the patient is returning to the office.

Patient care—and our medical record—need to be specific to the individual patient. We don’t perform services based on an ICD-9 or ICD-10 code, nor do we bundle care just because we don’t want to miss something. We should evaluate each patient as an individual, and our assessment of their individual risk is based upon their history and physical findings. Some patients may require more or less testing than others.

For that matter, the same patient may require different levels of examination and testing on different visits; our records need to properly reflect that.

State Your Reasons
Keep in mind that medical care today is based on medical necessity—meaning that the level of the office visit performed and the additional testing ordered must be necessary for that individual patient.

Also, remember that the CC requirement can be fulfilled properly if you direct the patient to return to the office for a specific reason at an appropriate interval. So, perhaps the plan section of our medical record should include a statement such as: “Patient to return to clinic for evaluation of IOP and optic nerve Q3 months or PRN should additional symptoms arise,” rather than: “RTC three months for glaucoma check.” The former statement tells the record what I want the patient to do and why I want him to do it, while the latter provides no explicit reasoning or medical strategy.

Then, when the patient returns, the CC should read: “Patient returning to clinic per doctor-directed order for evaluation of IOP and optic nerve.” And, if you have orders pending for special ophthalmic testing, those could also be listed in both the plan and the reason for the visit.

Last but not least, be aware of current Correct Coding Initiative edits, which stipulate whether you can perform specific ophthalmic tests on the same day. For example, you cannot do both an anterior segment OCT (92132) and a posterior OCT (either 92133 or 92134) on the same date of service.

Creating a medical record that is both specific and individualized for the patient is critical. Your medical record is your greatest weakness and your most powerful weapon—it’s the only thing that a carrier can use against you in an audit, and it is the only thing you can use in your defense. Most importantly, it’s one of the few things that you, as a physician, have total control over.

So, try to make your medical record perfect; not only will it help you pinpoint your patient care, but help protect you, too. n
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