Coding Q&A

Medicare audit traps for retina practices


Beware These Medicare Audit Traps for Retina Practices


Both consultants and retina practices have noticed the increased audit environment. In this column, I will explore specific areas in outpatient office visits now targeted for increased audit scrutiny.


Modifier 25 (Significant, Separately Identifiable Evaluation and Man agement Service by the Same Phy sician on the Same Day of the Procedure or Other Service) is the modifier used to engender payment for both the office visit and minor surgery procedure (one with a global period of 0 or 10 days) when performed on the same day. Its use has been under the OIG (Office of the Ins pector General) for some time.

This modifier has been overused in the retina practice in conjunction with intravitreal injections.


► Do not use modifier 25 on the office visit when the injection has been previously scheduled.
► Do not use modifier 25 if the chart documentation reflects that the purpose of the examination is the injection itself.
► Do not use modifier 25 if you are following a protocol or participating in a clinical trial that specifies injections at given intervals.


Office visits have changed this year with the elimination of the consultation codes and Medicare's instructions on what codes to use.

For regular office visits performed in an outpatient setting, the office is the place of service. However, there are some other variations.


► If you are requested to see an inpatient (formerly inpatient consultation), you would code Initial Hospital Visit for the first encounter (appending AI modifier if you are the admitting physician) and Subsequent Hospital Visit for further encounters.
► If you use your office to facilitate the exam, you still must code the above codes since the patient's status, according to Medicare, is inpatient. You should not code outpatient visit codes (E/M or Eye Codes). Recovery Audit Contractor audits have been initiated on this point.
► If you are requested or elect to examine a patient in the Emergency Department, you should code the ED codes and not outpatient codes.


Much to the chagrin of providers, Medicare's chart documentation requirements are such that often duplicative entries are necessary in the chart. The most common example of this is the “interpretation and report” requirement for diagnostic tests and similar information required for the Impression and Plan.


► For the Review of Systems, make sure you have listed organ systems and not merely disease entities. For higher-level examinations, you need more than 10 organ systems documented — auditors will not count disease entities.
► Be able to document either normal or abnormal for both Review of Systems/Past Family and Social History (ROS and PFSH) and the 14 elements of the Examination. Anything abnormal must be further described.
► Be careful of automatic negative defaults on EMR systems and be aware of using squiggly lines through all boxes rather than individually noting each box on paper forms.
► The interpretation and report must address the diagnosis, comparative data and, most importantly, the clinical management. The latter probably will also appear in your Impression and Plan. Make sure that the interpretation and report also has that information. Incomplete documentation, especially for the hig her level examinations, of the HPI (History of Present Illness) and the ROS and PFSH, is the single most frequently cited reason for downcoding according to Medicare contractors. 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.