Feb 17, 2026
Written By Elizabeth Cifers
Retina specialists are no strangers to complexity: ocular pathology, ever-evolving treatment protocols, and full clinic schedules already present plenty to manage before billing even enters the picture. Yet one of the quieter forces shaping retina reimbursement is something many physicians rarely see directly: National Correct Coding Initiative (NCCI) edits.
If that phrase makes your eyes glaze over, stay with me. Understanding the intent behind these edits (not memorizing them) can help physicians and practices avoid denials and reduce audit risk. It may even support more predictable revenue. As most administrators will agree, predictability is a beautiful thing.
At its core, NCCI exists to promote accurate coding by preventing inappropriate payment for services that should not typically be reported together. Think of it less as a regulatory hurdle and more as a guardrail that reflects how care is normally delivered.
Two primary types of edits affect retina practices: Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs). Although the names may sound vaguely intimidating, the concepts are fairly logical once you step back from the acronyms.
PTP edits assess whether two services are typically performed together or whether one is considered part of the other. In other words, Medicare and many commercial payers ask, “Is this truly separate work, or is it already included?”
In retina, where diagnostic tests, minor procedures, and surgical decisions frequently intersect, this issue is more significant than it may appear. It requires thoughtful documentation rather than reflexive billing patterns. Clinically appropriate care is often expected to generate multiple billable services. Sometimes it does. Sometimes it clearly does not.
The key is documentation clarity.
The strongest documentation eliminates ambiguity. Separate anatomical sites, distinct clinical reasons, or services performed during separate encounters should be evident in the note without requiring interpretation. Auditors are not mind readers. Auditors and payers should not have to infer what physicians already know. If the note does not clearly explain why the services are distinct, the claim begins to stumble before it even leaves the clearinghouse.
A practical mindset shift helps here: do not document to “get paid.” Document to explain your medical reasoning so thoroughly that payment becomes the natural outcome.
While PTP edits focus on whether services belong together, Medically Unlikely Edits address volume. These limits, based on clinical logic and common claims patterns, are designed to flag unusually high unit counts before payment.
The type of MUE is critical because it determines whether additional units can be considered:
This leads to an important point: exceeding an MUE does not automatically result in payment, even when the care is justified. MUEs are claims-editing tools, not clinical judgment tools. Many MUEs have firm payment limits, particularly for DOS edits.
When care legitimately exceeds usual thresholds, the documentation must clearly specify why the encounter was unusual and why extra units were needed for that patient on that date. Although this does not remove the edit, it is crucial for any claim appeal.
Not every service has an MUE, and MUEs change periodically. Retina practices benefit from documentation that consistently explains the physician's reasoning for care, not just when care deviates from routine patterns, rather than tracking the MUE value.
Rarely is it intentional. More often, issues stem from operational rigidity:
• Templates that produce cloned documentation instead of individualized patient records.
• Assumption that “we always bill it this way” equals compliance.
• Vague documentation.
NCCI edits tend to expose these gaps in documentation efficiently.
Which is why high-performing retina practices periodically review denial data, educate physicians and scribes, and ensure documentation aligns with necessary, supportive information.
NCCI edits are intended to ensure proper reimbursement based on work performed, not to limit necessary care. When documentation clearly explains the physician's reasoning and medical necessity, many billing concerns are resolved.
And while no physician went to medical school dreaming about coding edits, understanding their intent is part of protecting the financial health of the practice you work so hard to sustain.
After all, retina already provides enough surprises. Your revenue cycle should not be one of them.
If NCCI edits seem like an unfamiliar obstacle — or if denials reveal documentation gaps you hadn't noticed — Elizabeth can help. We collaborate with retina practices to clarify documentation, minimize preventable risks, and improve predictability in the revenue cycle.
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