Considering a Chart Review?

Following is a series of questions to help determine the motive, scope and depth of the chart review (audit) process. Each practice’s needs are different and your answers to these questions will help us determine the best way to assist the practice with its needs. There are no right or wrong answers, but the different concepts expressed in columns A and B can be a significant aid in determining the end result.

Column A

/ Column B

DETERMINE MOTIVE:

What has prompted the request for an audit and how will the audit results help you?

  • I just want to know if we are doing things correctly.(i.e., filing claims accurately, being paid for everything we do for the patient).
  • I want to find out how we would do in the event of a Medicare audit.
  • I want someone to review our coding and documentation.
  • I could use some help analyzing a recent change (i.e., new doctor, new ASC, sale or acquisition).
/
  • We recently received a request for records from Medicare, and I am anxious about it.
  • I think we may have an unhappy employee, former employee, patient, and or physician who could be a whistleblower.
  • I’ve received a subpoena for records.
  • We have a compliance plan, and an annual audit is required.
  • We are under a Corporate Integrity Agreement with the OIG and it requires annual audits by an outside auditor.

DETERMINE SCOPE: Is there a specific issue involved, or is the concern broad-based?

  • There is no specific concern.
  • I want to look at all types of services.
  • I want to review claims for all payers.
  • The issues are broad.
  • I want the review to be comprehensive.
/
  • I want to review a specific doctor, location, or department.
  • I am interested in only exams and tests.
  • I want to focus on particular surgical procedures.
  • I only care about Medicare or Medicaid claims at this time.

DETERMINE TIME FRAME:

Will the audit include past claims, or do you want to review claims before they are submitted?

  • I only want to look at services that have not yet been billed. This way I can make corrections before claims are submitted (prospective).
/
  • I want to look at claims that have already been submitted and paid (retrospective).

DETERMINE TYPE OF REPORT:

Is the report to be subjective and qualitative, or do you expect it to be quantitative?

  • I want a verbal report only.
  • I want a written report with suggestions for improvements.
  • I would like the report in the form of a letter summarizing the results; no details..
/
  • I expect a comprehensive report with statistical analysis of errors.
  • I want detailed, quantitative information related to specific charts.

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Chart Review Considerations

Before a chart review takes place at a practice, a number of considerations must be made in order to determine the scope and logistics of a chart review. The fill-in-the-blank table below will allow you to outline some preliminary information for the chart review.

How many of each?

Ophthalmologists / Surgeon / Non-Surgeon
General Ophthalmology
Cataract / Anterior Segment
Cornea / Refractive
Glaucoma
Retina
Pediatric
Oculoplastics
Neuro-ophthalmologist
Optometrists
Ambulatory Surgery Center(s)
CRNA(s) / Anesthesiologist(s)
Optical Dispensary(s)
Satellite Office(s)
Are all the charts stored in one location? Yes / No

How many years of services would you like us to review?

[ ]Current services only

[ ]1 year

[ ]2 years

[ ]More than 2 years

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