Ophthalmology has many types of examinations and a complex correspondence between examinations and disease names, making it a department prone to rezept audit deductions. Unlike returned claims, audit deductions in principle cannot be re-claimed, and the payment for the care actually performed cannot be recovered. That is precisely why a mechanism to "not cause" deductions—rather than "responding after they occur"—is important. This article organizes how to assign disease names and cautions in claiming to reduce ophthalmic rezept audit deductions, in line with the review approach.
How do audit deductions and returned claims differ?
First, as a premise, processing by the review and payment organization includes "audit deductions" and "returned claims."
- Audit deduction (reduction of points): The content of care is judged inappropriate against the rules of insured medical care, and points are reduced. In principle, re-claiming is not possible
- Returned claim: When it is difficult to judge appropriateness, or when there is a deficiency in the description, the rezept is returned to the medical institution. It can be corrected and re-claimed
The review committee reviews whether the content of the rezept conforms to rules such as the medical fee schedule and the regulations governing the conduct of medical care. Because audit deductions cannot be re-claimed, their impact on revenue is direct. In ophthalmology in particular, cases where "the examination was performed but there is no disease name to support it" tend to lead to deductions, so disease-name management is at the core of deduction countermeasures.
Patterns in which ophthalmic audit deductions occur easily
Here are the typical patterns in which audit deductions and returned claims occur easily in ophthalmic rezepts.
1. Missing disease names corresponding to examinations
In ophthalmology, each examination requires a disease name (indication disease name) that serves as the basis for performing it. If the disease name corresponding to the performed examination is not recorded on the rezept, it becomes subject to audit deduction. In particular, it has been pointed out that for patients who visit ophthalmology after visiting another department, forgetting to assign the ophthalmology-side disease name tends to occur.
2. Inconsistency in dates between disease names and examinations, procedures, or medications
If an examination is billed on a date earlier than the start date of the disease name, or if medications and examinations continue under an old disease name that should already have resolved (a so-called "dead disease name"), consistency is questioned. Lax management of the start and outcome (resolution/discontinuation) of disease names becomes a cause of deductions and returned claims.
3. Inconsistency regarding the frequency or number of examinations
When the same examination is repeated within a short period, it may be deducted if the necessity cannot be read from the disease name or clinical course. Attention to the interval between examinations is also needed.
4. Nonconformity due to "provisional" disease-name assignment
Assigning excessive disease names out of fear of deductions (the so-called abuse of "rezept disease names") instead invites divergence from the actual state of care and creates distrust in the review. As a rule, disease names should be assigned accurately and as needed, in line with the actual state of care.
Basics of assigning disease names and claiming to reduce deductions
- Always assign a corresponding disease name to examinations, procedures, and medications: Confirm that an indication disease name is linked to the medical act performed
- Correctly manage the start date and outcome of disease names: Enter the outcome for resolved disease names, and do not leave old disease names unattended
- Assign disease names in line with the actual state of care: Avoid the abuse of unnecessary disease names, and attach appropriate comments in cases requiring detailed symptom notes
- Clearly distinguish the left and right eyes (R/L): Because disease names and examinations often differ between left and right in ophthalmology, thoroughly record the site
- Confirm revisions and local rules: Because the handling of reviews differs by revision and region, confirm the latest information
The basis of these is "physicians and medical clerical staff checking each case with their own eyes," but as the number of cases increases, there is a limit to manual checking.
Deduction countermeasures with AI Karte
"AI Karte," developed by Pottech, is an integrated rececon type (chart and accounting/billing on the same foundation) equipped with AI rezept checking, and supports ophthalmic deduction countermeasures as a mechanism.
- Reconciling disease names with billing: The AI checks for the presence of disease names corresponding to the examinations, procedures, and medications performed, detecting missing disease names in advance
- Linkage of chart and billing: Because care records are directly reflected in billing, inconsistencies between records and claims are reduced
- Advance detection of missed billing and errors: AI rezept checking surfaces risk before submission, nipping the seeds of returned claims and deductions
- Integrated management with examination data: Because examination values and images are linked to the chart, the basis for examinations is easy to trace
Precisely because the chart, examinations, and billing are not fragmented, the AI can perform checks that understand both the "content of care" and the "content of the claim." This is a strength unique to the integrated type, difficult to realize in a configuration where the electronic chart and the rececon are separate.
In closing
The key to reducing ophthalmic rezept audit deductions lies in accurately assigning disease names corresponding to examinations, appropriately managing the start and outcome of disease names, and matching the actual state of care with the content of the claim. Because audit deductions cannot be re-claimed, a mechanism to "prevent them before submission" is more important than anything. Because the handling of reviews changes with revisions and region, always confirm the latest official information when operating.
Through the provision of AI Karte, Pottech serves as the optimal business partner for clinics—supporting not only better working conditions for physicians, nurses, and medical clerical staff, but also helping clinics achieve to the fullest what they want to accomplish.
For details, please do not hesitate to contact us.
References and Sources
- Social Insurance Medical Fee Payment Fund: The Significance of Review
- Social Insurance Medical Fee Payment Fund: Review and Payment of Medical Fees - Workflow
- Ministry of Health, Labour and Welfare: Medical Fee Schedule (Igaku Shinryo Hoshu Tensuhyo)
Note: The handling of audit deductions and returned claims and the review criteria differ by medical fee revision, by review and payment organization, and by region. When claiming, be sure to confirm the latest information published by the Social Insurance Medical Fee Payment Fund, the National Health Insurance Organizations, and the Ministry of Health, Labour and Welfare.