Jul 29, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Perhaps you’ve heard the term “chart audit” before, or your retina practice has recently been selected for one. If you don’t know what a chart audit is or need a refresher—it’s a payer review of one or more medical charts at some point before or after the claim has been paid. The audit can uncover billing errors and result in denials or recoupments that could add up to hundreds to thousands of dollars, which is why the potential for chart audits can create a lot of anxiety for practice physicians and administrators.
When facing a current or possible future chart audit at your retina practice, it can be helpful to have an idea of what they typically look like, along with a plan for what to do to correct errors when a chart audit occurs. Keep reading for clarity on these topics.
Chart audits start with a pre or post-payment payer request for medical charts. The payer request indicates the patient and service date with a specific physician. However, some requests do not have the physician's name on them, but when pulling the chart notes, you can figure out the physician or procedure code the payer is reviewing. Sometimes, it may be a mix of physicians and procedures with no discernible pattern. Depending on the payer's findings, they could find no issues, they may deny the claims associated with the notes reviewed on a pre-pay audit, which means no payment, or they may recoup some or all of the payments for a post-pay audit. As always, medical providers can appeal denials if they believe they are incorrect.
Suppose the chart audit is part of the Centers for Medicare and Medicaid Services (CMS) Targeted Probe and Educate (TPE) program. In that case, it will focus on a single code or a group of related codes—either an item or service with a high national error rate or one for which your retina practice has high error rates or unusual billing patterns. The Medicare Administrative Contractor (MAC) will review 20-40 of your claims and the supporting charts. If errors are found, you will receive education on how to correctly bill that item or service.¹
Retina practices are at risk of a chart audit due to legitimate but elevated utilization of high-level E/M codes. Learn more.
Some retina practices request the assistance of a specialized medical coding and billing consultant when they receive a pre- or post-payment request for medical charts. The consultant can review the charts for errors, provide the practice with a reliable prediction of the chart audit outcome, and help the practice identify sources of errors to address, mitigating practice risk for future chart audits.
Whether you work with a consultant or not, you’ll want to perform an investigation when you gather the chart audit documents. Start by reviewing the chart notes the payer is reviewing. If you find errors, dig deeper, even widening your investigation to other chart notes as the findings indicate a possible pattern—the payer may do the same. You may identify specific physicians, codes, or locations (if you have multiple offices) with errors. While you can’t fix most incorrect chart documentation after the fact, you can coordinate the training your team needs to chart appropriately in the future.
Note: If the chart audit is part of the TPE program, know that a “passing grade” doesn’t mean the entire chart is correct. Remember, these audits focus on singular items or services and the documentation that supports them only.
If your retina practice is selected for a chart audit, don’t panic—breathe. Whether it’s part of the TPE program or another payer audit, audits are expected in medical administration. Errors will likely be found, and denial of payment or recoupments may occur, but a chart audit is an excellent opportunity to learn and improve your retina practice.
Retina coding and billing consultant Elizabeth Cifers can provide the expert review your practice needs in the event of an audit. Or you can proactively hire Elizabeth to assess your retina practice’s risk of a chart audit or perform an audit to catch and correct errors—including training staff in proper coding and billing—before a payer flags your practice. Elizabeth has the specialized experience your retina practice needs, with decades in coding and billing roles, including 13 years at a retina practice and a position at a leading eye care consulting firm. If your retina practice could benefit from her help, book a free consultation with Elizabeth here.
Source:
1Centers for Medicare and Medicaid Services (CMS) (2023, September 6). Targeted Probe and Educate. CMS.gov. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-and-educate-tpe. Accessed July 19, 2024.
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