Sep 30, 2025
Written By Elizabeth Cifers
In retina, as with all medical records, correct and appropriate documentation isn’t just a best practice; it’s a legal and financial safeguard. As payer scrutiny increases, retina specialists must ensure their medical records clearly justify the need for the office visits, diagnostic tests, and procedures. ‘Medical necessity’ is the latest buzzword, but it’s the cornerstone of audit-proof billing. Without adequate documentation, even clinically appropriate visits, tests, and injections can result in denials, delayed payments, or potential accusations of fraud or abuse.
Understanding how to document medical necessity, particularly for high-cost items such as intravitreal injections, as well as more routine office visits and diagnostic testing, is crucial for maintaining compliance and protecting the financial health of your retina practice.
Medical necessity indicates the services are ‘reasonable and necessary’ for diagnosing or treating a patient’s condition, are supported by clinical evidence (the chart documentation), and are consistent with accepted standards of care. CMS and commercial payers rely on documentation in the medical record to determine whether a billed service meets the definition of medically necessary.
For retina practices, this includes:
• Diagnoses supported by clinical findings from the exam or diagnostic testing.
• Documented reason for selecting a specific treatment plan or drug.
• Documentation that conservative or less invasive options were considered or attempted, when applicable, and the outcome of these options.
• Documentation supporting the need for continued therapy, such as disease progression or recurrence.
Supportive documentation begins with thoughtful workflows and ends with clear, accurate, and defensible notes. While a patient’s history builds over time, each visit must be able to stand on its own and fully support the care given on the service date. Here are several ideas to strengthen the medical necessity narrative in your charts:
1. Link Clinical Findings to Treatment Decisions
Never assume payers will connect the dots – the documentation should provide the connection. Indicate why treatment was performed (or held) based on the patient’s complaint or reason for the visit, the exam findings (if an exam was performed), and how diagnostic test findings impacted the decision.
2. Document Changes Over Time
When continuing, holding, or wishing to change the drug for injections, describe the patient’s response to therapy. The documentation should always support the reason for the treatment plan. It is critical to state whether the patient is improving, worsening, or is stable. Chart notes with no variation can raise red flags.
3. Avoid Cloned Notes
Copy-paste or pull forward features may save time, but without proper editing for the current visit, it can erode the integrity of the record. If every visit looks the same, it may appear that the physician is not actively managing care. Remember, the chart documentation is the only ‘proof’ that exists for the medical necessity.
Whether the auditor works for a payer or the government, they review records to identify patterns suggesting services may not be necessary. Red flags include:
• Identical (cloned) exam findings across multiple visits with no changes.
• Missing rationale for diagnostic tests ordered.
• Poor or lack of updated clinical findings to justify continued injections or other treatment.
• Frequent use of high-level E/M or eye codes without supporting complexity.
Defensible documentation should connect the dots for patient care on the service date and have supportive evidence in the documentation.
In retina practices, documenting medical necessity is not optional. The stakes are too high to have routine denials and recoupments due to a lack of supportive medical necessity. Intravitreal drugs can quickly bankrupt a practice. From diagnosis to treatment plan and everything in between, each note should support the care delivered by connecting the dots. Practices that prioritize documentation quality reduce denials, withstand audits, and maintain a healthy revenue cycle.
Need help reviewing or strengthening your documentation workflows? Contact Elizabeth Cifers Consulting for expert support in retina billing compliance and medical record integrity.
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