Coding Q&A

Top Issues in Medicare Retina Audits


Top Issues in Medicare Retina Audits


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.

As the Medicare audit environment intensifies, retina specialists should be focusing on preventive measures that include correct chart documentation. All types of audits are increasing and the stakes are getting higher. Here, I review the various types of audits you can expect and the issues on which you may be audited.


RAC (Recovery Audit Program)

Originally known as Recovery Audit Contractor, from which the moniker RAC is derived, these audits are expanding at a rapid rate. RAC audits are usually either automated, semi-automated (data-mining audits), or complex (medical records audits). Here are some of the current retina issues posted:

Ranibizumab/bevacizumab/aflibercept. The posted issue for all of these semi-automated audits states:

Potentially incorrect billing occurred for bevacizumab claims billed with an ICD-9-CM code that does not support medical necessity according to existing Medicare policy, FDA labeling, accepted guidelines, approved compedia, or other Medicare rules and regulations, when no additional documentation is received from the provider for complex review within the 45-day response period.

TIP: Many of the incorrect billings emanate from incorrect data input by the billing department. You should appeal any refund requests with a written explanation of what occurred. Also, stress the importance of correct data entry and make sure no mistakes appear on your encounter forms. Remember, if it is a diagnosis not listed in the Local Coverage Determination (LCD), it makes the service noncovered.

Verteporfin. Semi-automated audits for photodynamic therapy were based on the outdated National Coverage Determination (NCD) that had not been revised. The original NCD, required fluorescein angiography (FA) before treatment. The latest revision 80.3.1, requires either FA or OCT.

TIP: Fight back. Even refund requests made before the revision can usually be reversed. It is important to win these because the supply is at stake as well as the service.

CERT Audits

A focus of Comprehensive Error Rate Testing audits is that a signature appear wherever one is required, either electronic or manual — that is in operative notes, chart notes, orders, and interpretation/report forms for diagnostic tests. (For detailed instructions, you may e-mail me at for copies of my newsletters on those subjects).

MAC Pre-/Post-Payment And Utilization Audits

You can expect to see these various types of audits from your Medicare contractor: pre-payment, post-payment, and utilization, among others.

Some of the current pre-payment audits revolve around the high-level E/M and the Eye Codes. The Eye Codes are no longer sacrosanct, and Medicare administrative contractors (MACs) are starting to look at technicians’ roles in performing physician services. Technician work cannot count toward the level of the service. Utilization audits frequently focus on extended ophthalmoscopy and FA.

CPT codes copyright 2013 by the American Medical Association.



▶ Read your MAC’s LCDs and make sure your chart documentation is as specified.

▶ Take advantage of the free webinars your MAC offers.

▶ Subscribe to your MAC’s e-mail alerts. They only take a few seconds to scan and delete if they are not pertinent. These will notify you of upcoming webinars, changes in LCDs, and other valuable information.


▶ Fear or avoid having a professional external audit; it’s better if the auditor working for you finds any problems. You will be able to correct those.

▶ Forget you are playing roulette with the auditors. Sometimes your practice will be the object of an audit, even if you have done nothing wrong. RP