Coding Q & A

Audit-causing issues in the retina practice

Coding Q&A

Audit-Causing Issues in the Retina Practice


Medicare's increased emphasis on finding errors that lead to audits and other reimbursement problems are causing agita (knots in the stomach) in many a retina practice.

Let's take a look at the top 5:

1. Technicians or other ancillary personnel performing part of the examination.

The Chief Complaint/History of Present Illness is considered physician work by Medicare and must be performed by the physician. If the handwriting is not yours, you will be cited.

Have either a notation in your handwriting that this was performed by you or an attestation on the chart or in your letter stating the same.

This applies to examination elements as well. Any examination elements that are being counted towards the level of the service must be performed by the physician or they will be disallowed.

2. Signature issues.

Medicare now requires a very legible full signature or legible first initial and last name on the chart. Signature logs are acceptable as are attestation statements — but there are rules of preparation that must be followed.

The Medicare contractors/carriers have issued signature guidelines for authentication of Medicare services. Have your billing department pull one of these up and adhere to it. Do it immediately or face a possible audit.

3. Dilating drops must be part of the medical record and documented in the chart/EMR.

For E/M services and the ophthalmoscopy requirement for Eye Codes (depending on the Medicare contractor/ carrier), a dilated fundus examination is required. The documentation supporting that dilation was performed must be part of the medical record. In the old days, dilation orders were frequently written on the encounter form attached to the front of the chart. This no longer suffices.

Most paper chart forms have incorporated this — make sure it is part of your EMR as well.

4. Double dipping on extended ophthalmoscopy and E/M posterior segment elements.

Extended ophthalmoscopy cannot be counted as both the basic E/M examination elements of optic disc and posterior segment and the separately reimbursable diagnostic test, extended ophthalmoscopy.

Many retina specialists perform the examination up to where dilation is ordered and then go directly to extended ophthalmoscopy and still code a level 4 or 5 examination.

A level 4/5 examination requires 14 elements be performed, including optic disc and posterior segment. If they are not documented as having been performed and no condition is discovered that warrants further testing, then there is no medical necessity for extended ophthalmoscopy.

5. Modifier application for office visits.

Modifiers 24, 25, and 57 are used independently or in multiples in conjunction with coding office visits in order to engender payment.

Modifier 24 is used to engender payment for an office visit during the global period of another procedure unrelated to the original procedure.

Often, what a physician considers a complication or related to the original surgery is not what Medicare considers related. An example of this is retinal detachment occurring after cataract surgery. Be sure to capture all of these.

Modifier 25 engenders payment for an office visit on the same day as a minor procedure (0 or 10 day global period). Example: office visit + intravitreal injection.

Modifier 57 engenders payment when the initial decision for major surgery (90 day global period) is made.

Modifiers 24 and 25 may be combined with modifier 57. Example: patient in global period for cataract surgery now needs retinal laser surgery and the decision for surgery is made and procedure is performed that day. Both 24 and 57 would be attached to the office visit service code. RP

CPT codes ©2010 American Medical Association.

Riva Lee Asbell can be contacted at, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.