Sep 11, 2024
Apr 3, 2025
Written By Elizabeth Cifers
The chart audit is essential to your retina practice's compliance calendar. Out of all the tools in your toolbelt, it’s one of the best to measure the effectiveness of your compliance activities. Failing to schedule a routine chart audit can result in missed opportunities to prove the legitimacy of your compliance program, identify and correct documentation errors, and receive the reimbursement your retina practice rightfully earned—a must in today’s economy. Read on to learn about chart audits and why they should be conducted routinely.
A chart audit reviews your retina practice’s medical documentation against coding and billing standards, guidelines, and regulations to identify potential issues. Chart audits should be conducted at least annually but can be more frequent if an area of risk is uncovered or there is a concern about risk. They can be carried out internally or externally by a third-party retina coding and billing expert remote or onsite. The product of a chart audit is a written report of the findings, recommendations, and proposed corrective actions, whether the audit is performed internally or externally.
Routine chart audits offer the following advantages to your retina practice:
1. Helps your retina clinic stay compliant. This one is a no-brainer. Routine chart audits allow your retina practice to identify coding, billing, and documentation errors and correct them moving forward via improved processes and staff training.
2. Proves that your compliance program is more than just a piece of paper. Chart audits help measure the compliance program's effectiveness at your retina practice. When performed routinely, they can show whether compliance in identified risk areas improves or deteriorates over time. The chart audits should reveal a positive trend if your compliance program is effective. If it shows a negative trend, dig into that to see why.
3. May help you identify issues before insurance payers do. Routine chart audits can help you identify issues or errors at your retina practice internally before they become more significant issues that may result in payer-directed chart audits and recoupments.
Every retina practice should have a compliance program, and every compliance program should regularly schedule chart audits. Routine chart audits can help the practice management make the error-reducing decisions that will move the needle on practice profit—a paramount task in a world of diminished fees and increased personnel costs. They can also demonstrate the effectiveness of compliance efforts and keep your retina practice off of payer watch lists.
Partnering with a third-party retina coding and billing expert on chart auditing offers advantages. Expert Elizabeth Cifers, MBA, MSW, CHC, CPC, brings decades of industry expertise, giving her a keen eye for issues and error patterns. She knows what to look for after working with retina practices across the country. She is also better suited than an internal auditor to look objectively at the charts, catching issues they might miss. Schedule a free consultation with Elizabeth here.
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