Dec 9, 2025
Written By Elizabeth Cifers
Technology-assisted coding tools promise speed and efficiency, but they also introduce new compliance challenges. In retina practices, where complex encounters and same-day procedures are common, automation can help streamline documentation and billing—if used correctly. The Centers for Medicare and Medicaid Services (CMS) and the Health and Human Services Office of Inspector General (HHS-OIG) have both warned that while technology can support accuracy, it doesn’t replace professional judgment or audit oversight. The key is to use these tools intentionally by combining automation with governance, validation, and human review to ensure coding remains both efficient and defensible.
Before adopting any coding technology, a practice should establish clear accountability. Someone must be responsible for compliance oversight, typically the compliance officer, administrator, or physician champion. This person ensures that the software’s code logic, data sources, and update cycles are transparent and up to date. Vendors should be asked to explain how their algorithms apply CPT, NCCI, and ICD-10 rules, and to document how often those rules are refreshed. If other logic is used in addition to these three examples, the vendor should also disclose it.
Governance also includes documenting the validation process before deployment. Practices that keep evidence of pre-launch testing and approval can demonstrate due diligence if a payer questions coding accuracy. In short, without clear oversight, even the most advanced systems can produce errors with serious consequences.
Validation transforms technology from a convenience into a compliance safeguard. A solid approach begins with comparing technology-generated codes against human-reviewed charts in a side-by-side test, which often uncovers hidden risks. Retina-specific issues, such as modifier use, diagnostic test unbundling, and global surgery overlaps, should receive special attention, not to mention the levels of office visit codes.
Annually, after the release of CPT and HCPCS updates, along with the ICD-10 modifications, and each quarter, following the CMS NCCI updates, the tool should be re-evaluated. This guarantees that the system is not using outdated coding rules or mistakenly flagging new payer edits. When validation becomes routine, technology shifts from a “black box” into a measurable, predictable partner in accurate coding.
Even the best coding technology can't fix weak documentation. Retina practices still need to ensure that every test clearly includes the proper order, laterality, and interpretation connected to medical decision-making. Auto-filled phrases or duplicated text that repeat the same interpretation across visits are common findings in audits—and they undermine the chart's credibility. Procedure documentation, even for a “standard procedure,” varies from patient to patient, whether it involves a laser or an injection.
AI-assisted tools should encourage physicians to describe what was unique about today’s visit or testing instead of repeating previous language. Human oversight guarantees that the chart accurately reflects what was done for that patient on that day. The bottom line is that technology can speed up documentation, but it cannot replace clinical reasoning or clear medical necessity.
Technology can enhance compliance when practices set it up correctly. Built-in audit logs should track who accepted or modified each coding suggestion. These records show that staff reviewed the technology’s output, which should meet OIG expectations for human oversight.
Automated alerts can detect when services go over frequency limits or when documentation is missing, such as for a separately billable test. When teams respond to these alerts—rather than dismissing them—denials decrease, and documentation quality improves. Adding these safeguards fosters a culture of verification instead of assumption, making coding software a dependable part of the compliance system.
Training bridges the gap between technology and compliance. Staff and physicians must understand how the system works, what its alerts mean, and when human judgment should override automation. Regular review meetings help link internal audit findings, system prompts, and actual payer requirements.
When practices openly share audit outcomes, corrective action becomes a learning opportunity rather than punishment. Templates are refined, workflows become more efficient, and teams develop a common language for accuracy. Technology alone doesn’t ensure compliance—well-informed people using it responsibly do.
CMS and OIG consistently emphasize that automation does not eliminate accountability. Practices must continue to monitor for over-coding, incorrect modifier use, or duplicated documentation. Internal audits remain the most reliable method for demonstrating compliance readiness. Reviewing even a small sample of charts each month shows proactive oversight, which the OIG considers a key feature of an effective compliance program.
The principle is simple: “trust, but verify.” Technology should support your compliance goals, not define them. Keeping human validation central guarantees that automation enhances accuracy rather than increasing mistakes.
Technology can simplify coding, but it’s your processes and people that make it compliant. When retina practices pair automation with structured oversight, documentation validation, and regular audits, technology becomes a strength rather than a liability. The best approach is to let tools help with efficiency while your team ensures accuracy, judgment, and integrity stay front and center. With the right balance, smarter coding technology can truly lead to stronger compliance.
Ready to confirm that your automation tools are producing compliant results?
Elizabeth Cifers Consulting can help you evaluate documentation and coding outcomes, design targeted internal audits, and strengthen your practice’s compliance framework before small risks become costly problems.
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