Sep 16, 2025
Written By Elizabeth Cifers
In retina practices, patients are seen for many reasons, some of which are one-and-done, while others are seen once a month, and everything in between. The most frequent patient is seen for follow-ups and injections, so getting the documentation right isn’t optional. It’s essential. Even when mistakes are unintentional, poor or misleading documentation can have serious consequences, including audits, recoupments, and in extreme cases, legal trouble. That’s why it’s so essential to create a system where both clinical and billing workflows are aligned and accountable.
When we hear ‘fraud,’ we usually think of intentional wrongdoing, but that isn’t always the case. In medical documentation, fraud refers to any false, altered, or misrepresented information in the chart documentation used to support clinical or billing decisions. In retina practices, it may be
• Cloned notes that don’t reflect the current visit
• Backdated entries
• Billing for a higher level of service than was performed (upcoding)
• Documentation that doesn’t support why an office visit, diagnostic test, or procedure was necessary
Documentation risks aren’t always due to dishonest intentions. The issues can also arise from outdated workflows, insufficient training for physicians, technicians, or billers, or simply from working too quickly and not paying close enough attention to the details. The Centers for Medicare and Medicaid Services (CMS) and the Health and Human Services Office of Inspector General (HHS-OIG) have issued warnings to providers about these issues, particularly when pre-filled templates or copy-paste habits create the impression that a patient was examined more thoroughly than they were.
Retina commonly bills for injections, lasers, diagnostic testing, and office visits, all of which have specific documentation requirements. These requirements include the eye(s) involved, medical necessity, appropriate and correct diagnoses, and, when applicable, the proper use of modifiers. All of these factors need to be crystal clear.
Some common red flags that can raise payer concerns:
• Repeated use of identical notes that fail to reflect changes in the patient’s condition.
• Missing indications for doing repeated testing, especially when done close together.
• No supporting documentation for an office visit, e.g., significant and separately identifiable, on the same day as a minor procedure.
Even if there’s no fraudulent intent, these issues can create billing patterns, which can trigger scrutiny from Medicare, Medicare Advantage, and commercial payers.
Avoiding documentation risks isn’t just about policies. It’s also about creating a culture where documentation is taken seriously at every level. Everyone in the practice, including the physicians, scribes, techs, and billers, should understand that documentation is more than just a clinical tool. It’s a legal record and the foundation of billing compliance.
Regular training is one of the best ways to keep everyone informed. Ensure your team understands how to document medical necessity, avoid common pitfalls related to pull-forward or copy-paste errors, and support high-level billing with concise and clear notes. This is especially critical in retina care, where services are often repeated and treatments are expensive.
Internal audits can also identify small issues before they escalate into larger problems. These reviews should include documentation for all services rendered and ensure the codes submitted are supported. As an additional layer of protection, consider having an external retina-specific coding expert review your documentation annually or every other year. A fresh set of eyes can make a big difference.
Electronic health records (EHRs) can be a help in managing busy clinic days, but they can also introduce new compliance challenges. Retina practices should make sure templates don’t allow for over-reliance on auto-filled data. Fields like chief complaint, plan, and exam findings should require active input and be updated at each visit.
It’s also a good idea to periodically review EHR audit trails for HIPAA compliance. You may want to seek assistance from your EHR vendor or IT support to review the information and provide a report of the findings. The audit logs should track all access, authorized and unauthorized, to patient records.
Ultimately, chart documentation is about more than just getting paid or avoiding penalties; it is also a legal document that tells the clinical story for the patient. It protects your patients, your practice, and your reputation. By implementing the right systems for your practice, consistent training, and a proactive oversight approach, retina practices can create and maintain compliance and confidence in a complex billing environment.
Are you looking to enhance your practice’s documentation processes? Reach out to us. Elizabeth Cifers Consulting can help you develop sustainable systems that promote compliance and effective clinical care.
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