How to Ace Internal Chart Audits

Internal chart audits are an essential component of a compliance plan. These reviews can help you and your staff identify chart deficiencies; they also provide an opportunity for practice improvement and ongoing education. You can strengthen your chart documentation by focusing your next review on these common deficiencies.

MISSING PHYSICIAN ORDER

Testing services that are delegated to staff require an order from the treating physician prior to performing. This order should include: 1) the name of the test, 2) the eye(s) to be tested, and 3) the indication or diagnosis to establish the medical necessity of the service. An example would be: 1) fundus photography, 2) of both eyes, 3) for diabetic retinopathy. This key documentation requirement is easy to overlook, especially during a new patient visit. The order should be documented after the face-to-face encounter and based on the patient’s unique illness or condition. Routine or standing orders for testing is not covered by Medicare or any other insurance payer, even if pathology is found. Often, the physician order is documented on the previous encounter for the established patient visit. This information must be appropriately documented in the patient chart in the event of an audit.

CLONED CHARTS

In addition to the streamlined functionality of EHRs, copy-forward documentation presents the possibility for cloned chart records. While these can help clinicians reduce the time required to document a patient encounter, cloning charts can introduce errors if not handled correctly. When key information from a prior visit is available during the current patient encounter, it is essential to review, update, and eliminate unnecessary information to ensure the documentation is accurate.

The Office of Inspector General warned of the potential vulnerabilities inherent to EHRs—such as masking the authorship of a medical record or distorting information—and cloned charts can produce inappropriate charges, facilitate inflated claims, and possibly create fraudulent claims.¹

Information pulled from a previous encounter can populate an inappropriate chief complaint, history, findings, and assessment and plan. If the patient’s data are not reviewed and updated based on what is relevant for the current encounter, it can be considered cloned documentation and could be harmful during an audit.

As an example, consider a patient being seen for a scheduled panretinal photocoagulation in the right eye. The procedure note is documented appropriately, and no examination was performed. However, the patient’s assessment states, “based on today’s examination, an intravitreal injection of Avastin (bevacizumab, Genentech/Roche) in the left eye is recommended.” Clearly, this chart was cloned from a previous encounter and was not updated appropriately.

NO PATIENT IDENTIFIERS

It may seem obvious, but all chart documentation must include the patient’s name and identifiers. For example, in the local coverage article A57804 for scanning computerized ophthalmic diagnostic imaging or OCT (CPT codes 92132, 92133, and 92134), the First Coast Service Options section states, “every page of the record must be legible and include appropriate patient identification information.”² This language is found in other Medicare polices and reminds physicians that each page of documentation must include the information necessary to properly identify the patient.³

An easy way to check this during your internal chart review is to print the patient encounter and confirm that the patient’s name and identifiers are present on all pages. Some EHRs allow formatting of the print note and updates to the footer or header, which may allow you to inadvertently eliminate the patient identifier. Confirm your printed records are compliant.

Additionally, any chart record that is scanned into the EHR as documentation should include the patient’s name and identifiers, including consents, advanced beneficiary notices, and images. Always verify that all copies of the diagnostic tests include the accurate patient’s name and identifiers.

LACKING A CHIEF COMPLAINT

Evaluation and management (E/M) documentation guidelines now require a medically relevant history, which means the chief complaint and history should accurately establish the medical necessity for the patient encounter. Consider the patient returning for a scheduled intravitreal injection in the left eye for wet AMD and a medically necessary examination of the right eye for dry AMD. If the chief complaint only states, “patient is here for an intravitreal injection in the left eye,” the documentation does not establish the medical necessity for the examination of the right eye—nor does it document any symptoms or changes in that eye. Additionally, when appending -25 modifier to the office visit code for this visit, the chief complaint documentation would not support the significant and separately identifiable examination.

NO ASSESSMENT AND PLAN

For each problem addressed during a patient encounter, an assessment and plan should be documented. When it comes to cataloguing the diagnosis, include whether the patient’s condition is stable, progressing, or worsening. For the plan, include the treatment (eg, laser, injection, or surgery) or establish when the medically necessary follow-up should be scheduled. This will help you accomplish two things: selecting the appropriate level of E/M medical decision making and establishing the frequency of the evaluation necessary for the problems assessed.

For more documentation guidelines, consult the 2022 Retina Coding: Complete Reference Guide at aao.org/store or checklists for your internal chart audit at aao.org/retinapm.

1. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. January 2014. Accessed June 13, 2022. oig.hhs.gov/oei/reports/oei-01-11-00571.pdf

2. Centers for Medicare and Medicaid Services. Billing and coding: scanning computerized ophthalmic diagnostic imaging (SCODI). Accessed June 28, 2022. www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57804&LCDId=33751&DocID=L33751

3. American Academy of Ophthalmology. Local coverage determination policies. Accessed June 30, 2022. www.aao.org/practice-management/coding/lcd-policies/carrier-list