Ophthalmic surgeries are subjected to increased scrutiny as payers intensify their review processes to ensure proper documentation and billing compliance. Ambulatory Surgical Centers (ASCs) are not exempt from these audits, which focus not only on individual surgeons but also on the facilities themselves. Recent Targeted Probe and Educate (TPE) reviews have uncovered a significant error rate, with common issues including incomplete documentation and insufficient evidence to support medical necessity.1 The current SMRC project for cataract surgery also targets ASCs.2
Internal chart audits are essential for identifying errors, ensuring adherence to payer requirements, preventing costly mistakes, maintaining compliance, and improving the quality of patient care. This can be achieved by following these 10 key steps.3
Step 1: Identify Potential Audit Targets
Start by identifying the most frequently performed ophthalmic pro- cedures. Run a productivity report to learn the surgeries performed and modifiers used most often. ASCs are most likely to be audited on the procedures with the highest volume, so focusing on these will ensure that the audit is comprehensive and significant.
Step 2: Understand the Requirements
Become familiar with the payor requirements for each ophthalmic procedure. Begin by reviewing the policies of the top 5 procedures for your top 5 payors, including Medicare. Find the latest Medicare Local Coverage Determination (LCD) documents at aao.org/lcds. These guidelines will ensure that documentation meets the payor’s expectations and help avoid errors in coding and billing.
Step 3: Create a Checklist
Develop a checklist that incorporates each payor’s documentation requirements, specifically for the most common ophthalmic surgeries. This checklist will be vital for maintaining consistency in compliance efforts. Ensure that this checklist is kept up to date as payor policies change.
Step 4: Determine the Sample Size
Start with a small sample, perhaps one chart per surgical procedure. This helps identify possible vulnerabilities without overwhelming the audit process. If deficiencies are found, expand the sample to cover more charts. Auditing a larger sample will give a broader perspective and help identify patterns and systemic issues that need to be addressed.
Step 5: Gather All Pertinent Documentation
Print out all documentation for review, as if this was an external audit. This includes having access to the exam that determined the medical necessity for the surgery. Ensure the following are included in each chart:
- Date of service
- Patient identifiers on each page
- Compliant physician signature
- Testing results (if applicable)
This will allow verification that all required documentation is present and complete when the inevitable outside audit occurs, including any preoperative checks or safety measures.
Step 6: Perform the Audit
Use the checklist and set deadlines to keep the process on track. Correct any coding errors, and if necessary, submit voluntary refunds to the payor. Continue to assess the audit process to ensure consistency and accuracy. Document all actions taken during the audit to maintain a clear record for future reference.
Step 7: Analyze and Verify the Results
Once the audit is complete, create a report to analyze the findings. Look for recurring patterns or issues, such as common errors related to specific surgeons, procedures, or times. Identifying these trends will help target areas for improvement in both documentation practices and safety protocols. Ensure all audits and corrective actions are documented in a formal compliance plan.
Step 8: Share the Results
Communicate audit findings with all team members involved in documentation, coding, and surgical processes. While physicians are ultimately responsible for the documentation, allied health technicians, surgical support staff, scribes, coders, and billers all play a role in ensuring accuracy. Be sure to address any reoccurring errors in the communication to keep everyone on the same page.
Step 9: Create a Compliance Plan
Based on the audit results, develop a plan to address deficiencies and prevent future issues. Include input from the entire team to ensure the plan is comprehensive and considers all angles, from documentation to patient safety. Be sure to document ongoing education and training efforts to keep the team up to date on best practices for both compliance and safety.
Step 10: Implement the Plan
Once the compliance plan is finalized, implement it by clearly communicating the required changes to all parties involved. Hold team members accountable and continue to monitor progress through regular audits. Address mistakes immediately to improve both documentation accuracy and patient safety. Consistent monitoring and proactive adjustments will drive continuous improvement.
The audit checklist is a critical tool for ensuring consistent and accurate documentation practices. By following the steps outlined, such as identifying audit targets, determining sample sizes, and gathering pertinent documentation, ASCs can pinpoint areas of improvement in their processes. These audit procedures are not only essential for meeting compliance requirements, but also for identifying trends and areas that need attention. To illustrate how these practices work in real-world situations, let’s look at a few case examples that highlight how internal chart audits can lead to meaningful improvements and resolve common issues in ophthalmic ASCs.
Case Example 1: Missed Signature on Surgical Order Documentation
An ASC performing retina surgeries found that several charts lacked the required physician signatures. Upon conducting an audit, it was discovered that an error in the electronic health record (EHR) had mistakenly allowed the closing of the chart prior to the physician’s signature. Initially, it was thought to be a mistake related to the way the documentation was printed out, but the audit identified a pattern of this occurring during busy surgical days when a scribe was overriding the default setting which required the surgeon’s signature. The ASC worked with the EHR vendor and implemented a system where the override option was removed and physicians must always sign post-operative notes after the procedure, and included this step in their compliance plan to prevent future occurrences.
Case Example 2: Incorrect Modifier on Glaucoma Surgery Billing
During a chart audit for glaucoma surgeries, the ASC identified several cases where incorrect modifiers were applied, leading to claim denials. The audit revealed that coding errors occurred when coders were unfamiliar with the latest payor-specific guidelines for modifier usage in ophthalmic surgeries. To address this, the ASC assigned each coder to specialize in one of their top 5 payors’ modifier requirements, scheduled targeted training for the coding team, and updated their checklist to ensure modifiers align with current payor policies.
Case Example 3: Incomplete Documentation for Cataract Surgery
An audit of cataract surgery cases revealed that a few charts were missing complete documentation of required decreased vision and impact on the activities of daily living and pre-operative testing establishing medical necessity. The issue was traced back to inconsistent documentation practices among different surgeons. The ASC addressed this by developing a process which included a cataract surgery checklist to ensure all required documentation and tests were completed and documented. Regular audits were scheduled to verify compliance with this new process.
Well Worthwhile
Implementing a thorough internal chart audit process is essential for maintaining accurate documentation, ensuring compliance, and identifying areas for improvement. By following the steps outlined here, ASCs can effectively assess documentation practices and address any deficiencies. Regular audits not only help maintain payer compliance, but also foster continuous improvement in ASC’s operations, ultimately enhancing efficiency and accuracy in surgical procedures. OASC
References
1. Cataract Surgery Audits Include Ambulatory Surgical Centers - American Academy of Ophthalmology Accessed March 20, 2025. https://www.aao.org/practice-management/news-detail/cataract-surgery-audits-ambulatory-surgical-center
2. Cataract Surgery Notification of Medical Review - Noridian - SMRC. Accessed March 15, 2025. Accessed March 20, 2025. https://noridiansmrc.com/current-projects/01-125/
3. How to Perform Internal Chart Audits in 10 Steps - American Academy of Ophthalmology. Accessed March 20, 2025. https://www.aao.org/practice-management/news-detail/how-perform-internal-chart-audits-10-steps