Best Audit Preparation Practices For Your Ophthalmology Clinic

ophthalmology codes

Nobody loves an audit, certainly not the office staff responsible for coding and documentation accuracy. But if you’re proactive—and learn to think like an auditor—you’ll be able to develop better clinic policies and practices  before auditors come knocking.

For 2018, CPT® code changes have no effect on ophthalmology, but ICD-10-CM ophthalmology codes see several changes, with 57 new codes, 25 revisions, and 8 deletions. Improper use of codes or cloning of documentation would be audit findings with serious consequences for your practice.

Additionally, there are several “grey areas” where, despite your practice’s assertion that everything was documented correctly, the auditor can decide otherwise, according to ophthalmology compliance expert Jeffrey Restuccio. Restuccio discusses these lays out audit grey areas, as well as what would count as definite red flags for auditors as part of a 2018 Coding Updates Virtual Boot Camp with ProfEdOnDemand.

Beware of Cloned Documents

One major grey area for many ophthalmology practices is the issue of cloned documentation.

In creating patient notes, there is sometimes a fine line between maintaining consistent documentation and copy/pasting too much information. While it’s necessary for patient records to be consistent, each note should still be different enough that auditors would not consider them cloned.

With the increased use of Electronic Medical Records (EMR), cloned notes are now a primary target of ophthalmology audits. Some physicians have come to rely on the copy and paste feature of EMR to save time, according to Dr. Juan P. Cueva at the Chicago Medical Society. While this practice may seem to be more efficient than manually typing in everything, this type of documentation is not considered accurate or compliant.

So how to avoid an auditor finding your practice’s notes as cloned? First, have a written cloning policy for your practice. Second, don’t have notes with excess or irrelevant information, and include at least three unique elements in each note. Lastly, in the note for a certain date, report only what was relevant and managed on that date.

4 Questions Help You Prep For an Audit

Because many providers are not even aware of the grey areas in auditing, proper training is essential.  Other auditor-approved best practices include:

  • Always prove medical necessity when creating patient records and coding
  • Have written policies in place on issues such as cloned documentation
  • Ensure your practice has an updated LCD for each procedure performed


In addition, it’s important to ensure your clinic has detailed documentation outlining how audits are to be handled, and that this information is thoroughly reviewed with everyone employed at the practice. Grey areas should be addressed in this documentation, as should the various elements auditors will be scrutinizing. Be sure you answer these questions:

  • Are the records organized and legible?
  • Is there consistency in the records (but not cloning)?
  • Has all staff been properly and consistently trained?
  • Have the coding guidelines been followed properly?


When auditors arrive, be able to show them your compliance plan as well as proof that everyone in your practice has been properly trained on it.

Also, make it clear that you’re using a scoring system for Medical Decision Making (MDM) and that you have a policy against cloning patient notes. Prove to auditors that you understand the role of medical necessity, and be prepared to show how medical necessity is implemented in your practice.

Having Sound Practices in Place

Although an audit can certainly be intimidating, the implementing a proper compliance plan (and training staff to follow it!) will go a long way toward helping your practice survive and thrive. In his presentation, Restuccio guides you through the audit preparation process—as well as explains how to handle MDM, prove ophthalmology medical necessity, and use the proper eye care codes and modifiers. With so many intricate details involved in ophthalmology coding, your practice will be grateful for your invaluable depth of knowledge.

To join the conference or see a replay, order a DVD or transcript, or read more

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

error: Content is protected !!