Jul 8, 2025
Written By Elizabeth Cifers
In retina care, it’s not a matter of whether you’ll be audited, but when. With intravitreal injections and same-day office visits under scrutiny, being prepared is essential. A recent HHS OIG audit found that 42% of same-day E/M services billed with Modifier 25 lacked proper documentation, putting $124 million in Medicare payments at risk (OIG Report, 2024)1. These findings underscore the importance of accurate documentation, careful coding, and internal oversight to ensure that your billing holds up when the audit arrives.
In retina practices, frequent patient visits, with or without procedures, can make it tempting to rely on templated notes. The problem arises when those notes do not accurately reflect the clinical realities of the visit, and they fail to provide adequate support for the services billed. Payers and auditors require clear medical necessity for every visit, particularly when it coincides with a minor procedure, such as intravitreal injections.
Electronic health records (EHR) provide clear documentation, and the templates, autofill functions, and copy-paste features can optimize documentation in a retina clinic. However, excessive use and lack of customization can result in notes that appear copied or inaccurate. The issue is particularly concerning when the same exam findings or diagnostic test interpretations show up across multiple visits without reflecting actual changes in the patient’s condition. Cloned documentation is a problem that needs to be addressed to ensure that each visit doesn’t seem identical to the previous ones, whether it involves exams, test interpretations, or the impression and plan.
Diagnostic tests, including retina OCT, fluorescein angiography, fundus autofluorescence, and fundus photos, are vital for retina care. Problems occur when tests are over-ordered without a clinical indication or a plan to apply the information in the patient’s treatment strategy. Even if a diagnostic test is performed regularly, there must be clear, visit-specific documentation to justify its medical necessity on the service date. Payers, such as Medicare, require not only the results of the tests but also the clinical rationale behind ordering them and an explanation of how the test results influence the treatment plan.
Retina billing often requires the use of modifiers and, in some cases, multiple modifiers to indicate that services provided, either on the same day or during a global post op period, were distinct, separately reportable, or unrelated to other procedures. However, incorrect or unsupported use of modifiers is a common focus of payer data mining, which can lead to audits. Inappropriate use can suggest the physician or practice is separating services that should be bundled—a red flag for potential overbilling. To avoid this, practices must ensure that any modifiers used are supported by clear documentation that demonstrates why each service was necessary and how it differed from other services performed during the same encounter or global period.
Routine internal audits are essential for ensuring compliance and reducing risks in a retina practice. Regularly reviewing documentation and coding practices can help identify issues early, reinforce accurate billing choices, and improve documentation. These internal reviews not only prevent recurring mistakes but also create opportunities for timely education and correction.
In addition to ongoing internal efforts, having an external audit conducted by a retina-specific coding and compliance expert every one to two years is a smart strategy. A fresh set of trained eyes can validate internal processes, identify previously overlooked patterns, and provide objective recommendations to enhance compliance.
In retina billing, while we strive for perfection, we do make mistakes, so perfection isn’t the goal—preparedness is. Given the complexity of coding, the high cost of drugs, and the frequency of audits, every retina practice will encounter scrutiny at some point. What matters is how well your documentation, coding practices, and internal oversight withstand that scrutiny. By identifying common billing risks, investing in education, conducting regular internal audits, and bringing in outside expertise when necessary, your practice can shift from reactive to proactive. The result? Fewer surprises, stronger compliance, and a smoother path through any audit that comes your way.
Is your retina billing ready for audit-level scrutiny? It’s not about being perfect, it’s about being prepared. If you’re unsure whether your documentation and coding can stand up to a payer audit, let’s talk. I help retina practices identify risks, strengthen compliance, and reduce the chance of costly denials or recoupments. Schedule a free 30-minute consultation with Elizabeth here to discuss internal auditing, education, or documentation review for your team.
1Medicare Payments for Evaluation and Management Services Provided on the Same Day as Eye Injections Were at Risk for Noncompliance With Medicare Requirements. Issued on 05/27/2025. Posted on 05/28/2025. Report number: A-09-23-03014. https://oig.hhs.gov/reports/all/2025/medicare-payments-for-evaluation-and-management-services-provided-on-the-same-day-as-eye-injections-were-at-risk-for-noncompliance-with-medicare-requirements/
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