Aug 5, 2025
Written By Elizabeth Cifers
In a busy retina clinic, documentation can feel like another task to get through, but the documentation is directly related to your revenue cycle, so it must be done. However, when the chart documentation is incomplete or inaccurate, it can have a direct and at times significant impact on your bottom line. Payers rely on documentation to justify what was done and why. If that information is missing or unclear, your claim can be denied, delayed, or flagged for further review. Over time, these issues chip away at revenue and increase your risk of audits. The good news? Most documentation problems are fixable with awareness, consistency, and a little bit of effort.
Daily, you perform exams, review the diagnostic test images, and make important treatment decisions. However, if those actions aren’t reflected in the documentation, payers don’t consider them billable. This means that missing or incomplete notes can result in denied claims, regardless of the care provided. Thorough documentation isn’t about writing more. It is about capturing the patient's clinical story clearly and accurately. This includes chief complaint, history of present illness (HPI), exam findings, the medical decision-making process, and the reason any testing or treatment was performed.
Pull-forward or copy/paste features in EHRs can save time, but overuse or failing to edit properly creates risk. When notes look identical from one visit to the next, it gives the impression that the patient wasn’t examined or that services weren’t medically necessary. Payers are increasingly flagging records with repeated language and templated content that doesn’t reflect meaningful change, in other words, cloned documentation. To avoid this, make sure each visit note reflects the current encounter, not the last one, or the previous five. Update findings, reference new symptoms or changes to current issues, changes in information received from the diagnostic tests, and explain your clinical reasoning for the findings, even if the patient is stable.
Diagnostic testing is essential in the world of retina, but it has to be justified. Tests such as retina OCT, fluorescein angiography, or fundus photography must be linked to a clinical finding or concern noted during the visit. Routine or standing orders, even if common in your workflow, aren’t enough. Payers expect to see a reason in the documentation, whether it’s new signs or symptoms, treatment monitoring, or suspected disease progression. Without the link from the why to the findings and how the data is used to determine the patient’s treatment plan, diagnostic testing can be denied or deemed medically unnecessary.
Diagnostic testing is essential in the world of retina, but it has to be justified. Tests such as retina OCT, fluorescein angiography, or fundus photography must be linked to a clinical finding or concern noted during the visit. Routine or standing orders, even if common in your workflow, aren’t enough. Payers expect to see a reason in the documentation, whether it’s new signs or symptoms, treatment monitoring, or suspected disease progression. Without the link from the why to the findings and how the data is used to determine the patient’s treatment plan, diagnostic testing can be denied or deemed medically unnecessary.
One overlooked modifier or missing diagnosis code may seem insignificant. However, when these errors occur repeatedly—across physicians, locations, or services—they result in substantial revenue loss. Worse, patterns of repeated mistakes can lead to payer scrutiny or even audits. And what if that one missing item is documentation of the injection or the procedure? Documentation mistakes can quickly add up to significant financial loss. That’s why internal reviews are so critical. Routine checks of physician documentation and billed claims help identify problems early, allowing for quick corrections and staff education before larger issues develop.
In retina practices, documentation isn’t just about compliance - it’s directly tied to your financial health. Every note, every test, and every procedure needs to be supported by clear, complete information in the chart. Taking the time to write a straightforward, concise clinical narrative, justify medical necessity, and regularly review documentation can help protect your revenue and reduce audit risk. It's not about being perfect, it's about being clear, consistent, and proactive.
Is incomplete documentation draining your revenue? If you're facing denials, inconsistent reimbursement, or want to improve your processes, I can assist. I help retina practices enhance documentation, reduce audit risk, and safeguard high-value services, such as diagnostic testing and intravitreal injections. Contact me to schedule a review or learn how an internal audit can uncover and resolve issues that cost your practice revenue. Schedule a free 30-minute consultation with Elizabeth here.
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