Audit prevention is the best approach

Human nature often leads us to look through the rearview mirror rather than the windshield. We look at past performance as validation of our efforts. This can be particularly true when it comes to behaviors with medical coding and compliance. We, and our staffs, tend to develop patterns of behavior that allow us to get paid for services, testing and procedures, but which does not guarantee these behaviors will meet the standards of CMS or your carriers. Maybe 2019 can be different.


Each year, the American Medical Association, CMS and commercial carriers publish updates to foundational concepts, rules and regulations. Whether you rely on online or printed sources for your information — know the rules that you need to follow.


As primary eye care providers, we are obligated to know the type and the level of service we provide to patients. Take into consideration contractual obligations with respect to care provided.

There really shouldn’t be any confusion as we go into 2019 with respect to “do I perform a 920XX or 992XX code” with any given situation. The CPT requires us to code the service that most closely represents the service that we have in the medical record.

One approach could be to develop clear and concise protocols — via clinical vignettes —that can help guide those decisions. Review them with the other practitioners and staff members to help maintain clinical consistency.


The hallmark principle when ordering diagnostic tests is that of medical necessity. Tests must reach this benchmark to be appropriate to do. Tests cannot and should not be confirmatory of each other. In other words, if a test is run just to confirm another test, it is most likely not going to stand up to audit of medical necessity. Another compliance hallmark is that you need to complete an “Interpretation & Report” for each diagnostic procedure performed. Describe the clinical findings of the test, the reliability of the test and demonstrate how the test contributed to the clinical management of the patient.


The Correct Coding Initiative Edits are nationally based rule sets that determine what CPT codes can be performed on the same date of service or encounter. These are important to understand from the perspective of bundling or unbundling services, and also from the perspective of using modifiers appropriately should you need to “break” one of these rules, please make sure you have a current list of the modifiers required and that you clearly understand the definition and use of the modifier before submitting a claim. Misuse of modifiers pose a serious compliance risk that can lead to audits and penalties.


Proper medical record compliance is more than just a concept. Properly thought out, vetted and implemented it can be another tool for success. Whether it be the satisfaction of doing things right, providing appropriate levels of care supported by the medical record, increasing profitability or removing the worry of an audit — it is important to make sure you develop a path to compliance.


My time with OM has come to a close. With this being my final column, I would like to say “Thank you” to all of you for your comments and questions over the years. I hope that I have provided information that has benefitted you and your practice, and I wish my successor the very best in continuing the tradition and high standards that makes OM such a great publication. OM