Quick Check of Your EHR System for Compliance



For your own protection from insurance audits review this carefully.


We are providing this information because more practices are being audited every day. 

In the last year, all payers have increased the number of auditors and the penalties imposed.


This information has been compiled from discussions with insurance auditors and our wide experience with client audits.


Many EHR systems are not compliant! 


Nteon Practice Consultants finds this in our audits.

In defending practices that have lost insurance audits, we were told by the auditors that they find more often EHR systems to be non-compliant!


Unfortunately, many EHR vendors ignore this.


Some of the most common reasons practices fail insurance audits are Insufficient History, Lack of Medications documentation, and proper Review Of Systems. 

Doctors think their records are OK because their EHR system showed the exam was compliant.  Most EHR "Documentation Verification" is inaccurate, showing compliance when key requirements are not documented.  Auditors find these exams and deny those that had been marked by the system as compliant


In addition to History, we have prepared two simple tests for you to verify if your system meets compliance.  


It is important to clarify; there are many reasons for a failed insurance audit.  

These are only a few of the more common examples.


992xx E/M exams and Medical Decision Making (MDM)

(99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215)


If you bill 992xx E/M exams, there must be a section in your EHR system titled “Medical Decision Making.” 


There are three specific elements in this required category

·         Amount or Complexity of Data Reviewed

·         Diagnosis and Management

·         Patient Risk


If these are not in your exam (most systems do not have MDM) you will fail an audit!


For compliant 992xx exams you must document at least two of the three items.  These are specifically required! 


Note: These are defined in detail in EyeCOR in the "Exam Advisor" section.


Several EHR systems only have check marks for each of the three categories. This is not compliant since it does not justify how the physician arrived at these specific items.

The EHR system must specifically document which items are counted.  If not, the auditors will fail these examinations.


Many EHR systems only document terms like "Limited", "Multiple" or "Moderate".

Many vendors claim this as sufficient documentation even thought the requirements state otherwise. 



92004 and 92014 Ophthalmic Exams and Initiation of Diagnostic & Treatment Plan


If you bill either 92004 or 92014 exams, there must be a section in your EHR system titled “Initiation of Diagnosis & Treatment Plan.”  There are five different items.  You must document at least one for a compliant Comprehensive Ophthalmic Exam.  

·         Prescription of [New] Medications, [New] Lenses or other Therapy

·         Arrange Special Ophthalmological, Diagnostic or Treatment Services

·         Radiological

·         Consultation (Referral)

·         Laboratory Procedures   


If these are not specifically documented in your exam you will fail an audit!  Again, some vendors dispute this requirement and according to CMS the lack of this “Initiation of Diagnosis & Treatment Plan” is the most common reason for a denial of a Comprehensive Exam!  Note: This separate and in addition to the "Plan" in your exam.


Note: These are defined in detail in EyeCOR.


All the requirements for a Comprehensive Ophthalmic Exam are documented in the AMA Professional Edition CPT.  To verify for yourself refer to that document.  If your vendor disputes the requirement refer them to the AMA CPT manual!



We are providing this information because we see so many practices get hit with penalties exceeding $100,000 for a negative insurance audit! 
These practices  always say they believed their EHR system was compliant.


You need to be proactive and protect you and your practice.   
This is serious and expensive!

For more information or questions contact us:

Nteon Practice Consultants

Toll Free:  888-866-5367
email:        info@nteonconsultants.com