Clinical Scorecard: Coding & Compliance: 10 Steps to Bulletproof Internal Chart Audits

At a Glance

Key Highlights

• Increased scrutiny on ophthalmic surgeries by payers, particularly for cataract and glaucoma procedures.
• Common issues include incomplete documentation, insufficient evidence of medical necessity, and lack of physician signatures.

Guideline-Based Recommendations

Diagnosis

Management

• Create a compliance plan based on audit findings, detailing specific actions to address identified deficiencies.

Monitoring & Follow-up

Risks

Patient & Prescribing Data

Patients undergoing ophthalmic surgeries at ASCs.

Focus on ensuring complete documentation to support medical necessity.

Clinical Best Practices

• Address recurring errors promptly by implementing targeted training sessions for staff involved in documentation.

References

• Medicare Local Coverage Determination (LCD) documents