Nov 25, 2025
Written By Elizabeth Cifers
Diagnostic testing is essential in retina care, and the advances in technology have made it indispensable. These tests help monitor disease progression, guide treatment decisions, and evaluate outcomes. Since they are also high-volume, payers are increasingly scrutinizing whether each test was medically necessary and properly documented. Missing details can result in claim denials, repayment requests, and unwanted payer scrutiny.
Insurers require clear, documented justification that each test was essential to patient care. Denials often result from overuse or repeated testing without explanation, cloned interpretations, lack of documented interpretation, or mismatched diagnoses—essentially, a lack of medical necessity for the test. Every test must demonstrate medical necessity, appropriate frequency of use, and a clear clinical impact on patient management.
Each diagnostic test should tell a complete story and include an order specifying the test type, reason or indication, laterality, and when the test should be performed. For example, retina OCT, OU, wet AMD, at the next visit in 4-6 weeks. Documentation of the findings, interpretation, and how the results affect the patient’s care plan is also necessary. Without a documented interpretation and a report, the service is considered part of the E/M visit and not separately billable.
Proper documentation involves clearly documenting medical necessity and decision-making. Internal chart audits are the most dependable method for verifying compliance. Regularly reviewing a small sample of diagnostic tests each month can identify missing or weak orders, interpretations, weak medical necessity statements, or inconsistencies between documentation and claims. Sharing these findings constructively helps improve documentation accuracy, supports ongoing staff education, and reduces the risk of denials or post-payment reviews. An additional bonus is that it demonstrates the practice has an effective compliance program.
Thoughtful, payer-ready documentation reduces administrative rework and can enable faster reimbursements, especially when the payer requests the chart for review. When every test is justified, ordered, interpreted, and related to medical decision-making, audits pose less risk. The bottom line is that if it isn’t documented, it wasn’t done and isn’t billable. Strong diagnostic documentation safeguards both compliance and revenue integrity.
Ready to strengthen your compliance and keep more of what you earn? ECC can assist you in designing and conducting your own internal audit—or handle the audit process for you. Either way, you’ll gain a clear picture of risks, accuracy, and opportunities within your retina documentation and coding.
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