Approximately 70% of audit-related calls and emails to the Academy are from retina practices. Smart practices proactively prepare for audits, which are inevitable and are typically triggered by volume. Practices that react to an audit rather than prepare for it are at a disadvantage.

CMS and its Medicare Administrative Contractors (MACs) conduct several types of audits and investigations that can affect retina practices. This article reviews some of the ways your practice can prepare in advance so that these audits do not take you by surprise.

TARGETED PROBE AND EDUCATE AUDITS

CMS’s Targeted Probe and Educate (TPE) program is designed to help providers reduce claims denials and appeals, according to CMS. MACs conduct TPE prepayment audits, during which charts are reviewed and educational feedback is provided.

Practices with high-volume utilization of a particular CPT code may receive a TPE additional document request prompting the submission of 20 to 40 targeted chart records. Practices have 45 days to respond. The audit may consist of three rounds of prepayment review. After each round, audit results may be mailed or may require a personal review.

Passing your audit during the first two rounds is important. If a high denial rate is identified after round three, the MAC may refer your practice to CMS for further actions, including extrapolation; referral to the zone program integrity contractor, unified program integrity contractor, or recovery audit contractor; or 100% prepayment review.

FOCUS ON RETINA

Intravitreal injections are the top focus of TPE audits for retina specialists. These audits are performed by the MAC for the area where the practice is located, as illustrated in Table 1.

Targeting up to 40 claims prior to payment will affect cash flow. I suggest that you correct discrepancies in record-keeping now, so that your documentation meets the requirements regarding whether or not an exam is separately billable.

Intravitreal injections are not the only focus of audits. Codes 92014 (established patient comprehensive eye visit), 99222-99223 (initial inpatient exam), 99232-99233 (subsequent inpatient exam), and 99213-25 (E/M level 3 established patient exam), and emergency department visit codes 99284 and 99285 are also scrutinized. To see a more comprehensive list of audit targets, visit aao.org/audits. This sensitive web content will require your AAO membership login information.

RECOVERY AUDITS

The Medicare Recovery Audit (RA) program was created to identify and correct past improper payments to Medicare providers. RAs, which are facilitated by the MACs assigned by CMS, have targeted several retina services, including the inappropriate billing of intravitreal medication units. For example, incorrectly billing 1 unit of aflibercept (Eylea, Regeneron) instead of 2 units could be caught by RA auditors. In this case, an RA is your friend: Not only did it identify the costly error, but you will be paid for the additional unit.

RAs are performed in four regions by three contractors. The targeted retina services and regional details are outlined in Tables 2 and 3.

RA auditors conduct two types of audits. One is an automated review of claims data. This is a data-driven audit, and chart notes are not requested. When it is concluded, the physician receives a request for refund. If it is not repaid within a particular time frame, payment will be withheld from the physician’s next payable claim. If, for example, your practice submitted claims for injectable medications while a patient was in a skilled nursing facility, then the RA contractor will request a refund for the medication payment.

RA auditors may also conduct a complex review based on auditing-submitted chart documentation. In this instance, the physician will receive an additional documentation request and must submit claim documentation within 45 days.

Automated and complex reviews may be appealed by the physician when appropriate.

WHAT TO WATCH FOR: PHOTODYNAMIC THERAPY

CMS has focused on photodynamic therapy (PDT) documentation in its most recent high-volume complex reviews. There are three CMS national coverage determinations (NCDs) related to PDT and verteporfin (Visudyne, Bausch + Lomb), each of which has been revised over the years. When referencing an NCD for an audit, review the policy in place at that specific date of service. NCDs can be downloaded at aao.org/lcds.

PDT Documentation Checklist

The following checklist can be used when your practice receives an RA for PDT. Confirm the date of service and reference the appropriate NCD.

All of the following must be present before therapy begins:

  • Choroidal neovascular membrane (CNVM) secondary to ageā€related macular degeneration (AMD)
  • CNVM under the geometric center of the foveal avascular zone
  • Evidence of classic CNVM on fluorescein angiography (FA)
  • Area of classic CNVM at least 50% of the area of the total neovascular membrane
  • Retreatment with PDT is reasonable and necessary if, on re-examination, the ophthalmologist finds leakage from classic CNV on FA

Note that for claims with dates of service on and after April 3, 2013, use of OCT or FA to assess treatment response is permitted.

Effective April 1, 2003, PDT may be covered if used for subfoveal occult with no classic CNV associated with AMD, or subfoveal minimally classic CNV (ie, the area of classic CNV occupies < 50% of the area of the entire lesion) associated with AMD. These two indications are considered reasonable and necessary only when the lesions are small (ie, ≤ 4 disc areas) at the time of initial treatment or within 3 months prior to initial treatment; and when they have shown evidence of progression with the 3 months before initial treatment.

PDT is not covered for the treatment of juxtafoveal CNV lesions, extrafoveal CNV lesions, or dry AMD. It is also not covered if FA was unobtainable.

Procedure notes should include the following:

  • Diagnosis supporting medical necessity and appropriate indication for use
  • Relevant diagnostic testing services within the policy guidelines (ie, FA, OCT)
  • Physician order including medication name, dosage, and signature
  • Route of administration and site of injection
  • Dosage (mg) and volume (mL)
  • Medication wastage recorded (billing of wastage with -JW modifier required)
  • Completed consent
  • Legible physician signature, either on paper chart or electronic health record

PREPARE YOUR PRACTICE

Monitoring the types of audits being conducted on retina practices is the first step to strengthening your audit armor. Visit aao.org/audits to learn about auditing trends and targeted services for your region.

A comprehensive internal review can prepare your practice for the next audit. Identify the services performed in your practice and review the relevant current local coverage determinations (LCDs) detailed at aao.org/lcds.

When you review your practice’s protocols, review the frequency limitations, documentation requirements, and diagnoses that establish medical necessity. Create an internal checklist outlining the documentation requirements, and conduct your own targeted internal chart review. Confirm that your insurance claims accurately reflect your chart documentation. Take corrective action if deficiencies are found in your documentation, and educate all physicians and staff on the results of your review.

There are many types of audits to monitor, and targeted services that may directly affect retina practices. Being prepared with accurate documentation and appropriate coding is the best way to prevent a failed audit. Periodic reviews of audit targets and internal reviews will help protect your practice and minimize the impact of the inevitable request for records.