Mid-year is a great time to assess your medical records

We seem to align ourselves with specific dates. The beginning of the year always carries a list of resolutions, and the end of the month, quarter or year always has a laundry list of things to do. I suggest mid-year as the perfect time to conduct a self-audit of your medical records. To do so, let me bring some perspective on what the top issues for audit failure are in an ophthalmic practice.

  • Lack of medical necessity noted in the record:
    • For type of visit and level of visit
    • For special ophthalmic procedures and surgical services
  • Improper coding of office visits:
    • Overuse of 920X4 codes
    • Improper use of 92012 codes
    • Improper coding of 992XX codes, specifically approximating the level rather than actually coding correctly
  • Improper use of modifiers -25 and -59
    • Not meeting clinical use of or fulfilling definition of the modifier


Here are the steps to take to perform a self-audit.

  1. Gather reference sources, such as CPT book, ICD-10 book, CMS Evaluation & Management Guidelines (or visit online at ).
  2. Create a random sample. For example, choose every 17th record, organized alphabetically, until you have 25 records to evaluate.
  3. Evaluate the last one or two dates of service in each record, with these specific items in mind:
    a. Was the patient status of “New” or “Established” calculated properly?
    b. Did you properly determine the chief complaint that brought the patient in on that specific day?
    c. Did you acquire the appropriate level of history commensurate with the patient’s presentation?
    d. Did you perform the correct type of physical examination based on the patient’s presentation or contractual requirement from a third-party?
    e. Did you score your history of present illness, history level, physical exam and medical decision making properly when a 992XX code was performed or was the level of 992XX service just approximated?
    f. Was the level of exam appropriate for the specific patient presentation? In other words, did you perform the level of service that is commensurate with the patient’s presenting symptoms or issues.
    g. Did you properly determine all diagnoses specific to your examination? It is important to list all diagnoses found whether they are refractive, medical with respect to the eye, and medical with respect to systemic disease.
    h. Did you develop an appropriate plan? (Keep in mind that for any level of 920XX code you need to include the initiation of a diagnostic and treatment program.)
    i. If you ordered any special ophthalmic procedures, did you properly determine medical necessity for those procedures clearly and concisely? Did you include what to do with the patient, why you want to do that specific test and when the test should be done? For Example:

       i. Patient to RTC one month or PRN for further evaluation of IOP, assessment of optic nerve, and efficacy of new meds.
       ii. Order fundus photography (OD, OS, OU) secondary to presence of A/V crossing anomalies noted today.
       iii. Order OCT of optic nerve OU secondary to change in vertical optic nerve rim tissue noted today.
       iv. Patient to RTC one year or PRN for further diagnostic evaluation of nuclear sclerotic cataracts OU, noted today.

    j. Did you research the CCI edits to make sure you can actually perform the tests indicated on the same day? Further, if you used a modifier (specifically, modifier -59), did you read all documentation necessary to determine if your clinical application met the definition?
    k. If you performed a special ophthalmic test, did you properly complete an Interpretation & Report. (Keep in mind that the test is not complete and cannot be billed to a carrier or patient until this is done. It should contain the following:

       i. Clinical findings: Pertinent findings regarding the test results
       ii. Comparative data: Comparison to previous test results (if applicable)
       iii. Clinical management: How the test results will affect management of the condition/disease, such as:
          1. Change/increase/stop medication
          2. Recommendation for surgery
          3. Recommendation for further diagnostic testing
          4. Referral to a specialist/sub-specialist for additional treatment

    l. If you are having the patient back for a surgical procedure, did you review the surgical preamble, found in the CPT book, defining a surgical package and what is included in that – i.e. an office visit is almost always included in the definition and reimbursement for all minor surgical procedures and should not be billed separately using modifier -25.
    m. If using modifier -25, did you read all documentation, such as Appendix A of the CPT book, necessary to determine if your clinical application has met the definition?
    n. Did you complete an operative report? An operative report should contain the following:

       i. Patient’s name
       ii. Date
       iii. Preoperative diagnosis
       iv. Postoperative diagnosis
       v. Surgeon’s name
       vi. Indications for surgery
       vii. Procedure performed
       viii. Findings at surgery
       ix. Additional details, as needed


Conducting a self audit is an important part of any internal compliance plan. It can help easily identify areas of concern, areas where documentation is deficient or areas where documentation is supportive of the clinical services performed. Mid-year is a good time to take stock in what you have done in the past and how you are going to improve it in the future. Done properly, the value of “your stock” will only go up. OM