According to the Centers for Medicare & Medicaid Services (CMS), “Improper payments totaled $48 billion in FY 2010.”¹ To counteract this problem, CMS implemented a robust auditing process, which included both pre- and post-payment reviews.

Receiving a CMS audit is an unwelcome surprise for most practices; however, implementing a strategy from the beginning will mitigate stress and keep you organized throughout the process. Per CMS, “Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.”² As such, it is important to make sure you have a good team to gather the appropriate documentation for the audit request.

Below are a few tips to help you and your team maneuver through the storm.

BUILD YOUR TEAM

With any CMS audit, your practice will receive a letter or notification typically accompanied by an Additional Documentation Request (ADR).³ It’s important to treat each ADR as a “project” and appoint a team leader to organize the process. Usually, the medical records team identifies and pulls the requested chart documentation and makes copies. However, the medical records team may or may not readily identify all the necessary documents and/or subtleties of the request. Therefore, building a team that includes the provider associated with the audit, a clinical staff member and someone from the billing department to work together will ensure a satisfactory ADR submission.

SET AN INTERNAL DEADLINE

After the team leader assigns tasks such as gathering the medical records and drafting a response, set an internal deadline. Most CMS audit requests have a 30- to 45-day response window. With that in mind, set a due date for compiling the medical records, reviewing said records and preparing the packet(s) to send to the auditing entity.

To have adequate time to review coverage policies and compare them to the documentation in the submission, we suggest giving yourself as much time as possible and starting this project promptly. If an extension is needed, file for one immediately.

REVIEW COVERAGE GUIDELINES AND PUBLISHED POLICIES

A CMS audit request typically contains a reason for the request. For example, the Recovery Audit Program provides a list of approved issues, one of which includes “Cataract Removal: Medical Necessity and Documentation Requirements.”⁴ Often the request contains the applicable references and guidelines published by the Medicare Administrative Contractor (MAC) or CMS manuals. Some of these sources are “generic” with respect to the Medicare program, while others are likely specific to the request.

In addition to reviewing your MAC’s applicable Local Coverage Determinations) and Local Coverage Articles, find the references mentioned in the letter.

STAY ORGANIZED

Do not underestimate the value of an organized, easy-to-follow submission. After gathering the appropriate supporting documentation, label each document numerically and develop a “key” or draft a narrative explaining the submission. While this may sound like extra work, you are likely to fail the review if the person reviewing the submission is unable to find or decipher the information.

Eye care is notorious for unique abbreviations and acronyms, so attaching an abbreviation list is essential. Regardless of how common or routine an abbreviation may seem, include it on the list (eg, OD, OS, OU, IOP). The goal is to make it easy for the auditor to follow along.

DRAFT A COVER LETTER

Most CMS auditors are not eyecare-specific; therefore, I recommend drafting a cover letter describing where the documentation is located within the attached medical records packet. Since staying organized is critical, use the cover letter to explain relevant patient circumstances and walk the auditor through the submission by identifying the location of necessary information.

The labeled documents and the “key” you have created will prove handy when referenced within your explanatory letter(s).

MAKE COPIES

Before sending the packet, copy everything. This allows you to resend the information when, or if, CMS loses it. The copies also reflect the original submission and allow you to prepare for any necessary future appeals.

SEND SUBMISSION BY CONFIRMATORY METHOD

Unless you requested an extension, anticipate enforcement of the submission deadline. If a deadline is missed, a reviewer may determine the documents were not submitted, resulting in a negative outcome and possible recoupment.

There are several “acceptable submission methods” for an ADR, which include using a shipping service, a web portal or the Electronic Submission of Medical Documentation System via a Health Information Handler.^5,6 Regardless of the method, request a return receipt showing the time and date-stamp record of when the documents were sent and received.

BE PREPARED

The CMS audit process is certainly challenging. However, being prepared by developing an “audit team” and utilizing some or all these tips can help relieve the burden. Good luck! OM

REFERENCES

1. Parts C and D Recovery Audit Program: Program History and Authorities. CMS. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program-parts-c-and-d/Program-History-and-Authorities . Accessed Feb. 8, 2023.
2. Medical Review and Education. CMS. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/medical-review . Accessed Feb. 8, 2023.
3. Mock Additional Documentation Request (ADR). Novitas Solutions. https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00167901 . Accessed Feb. 8, 2023.
4. Approved RAC Topics. CMS. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics . Accessed Feb. 8, 2023.
5. Acceptable Submission Methods for Responses to Additional Documentation Requests (ADR). CGS. https://www.cgsmedicare.com/partb/pubs/news/2013/1013/cope23582.html . Accessed Feb. 8, 2023.
6. esMD for Health Information Handlers. CMS. https://tinyurl.com/y5rtzfa.2 Accessed Feb. 8, 2023.

Brittney Irwin, COT, CPC-A, CEP, is an associate consultant within the Billing, Coding and Compliance Division of BSM Consulting. In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.