May 27, 2025
Jun 9, 2025
Written By Elizabeth Cifers
When it comes to reimbursement in a retina practice, documentation is everything. No matter how well a procedure is performed, if it’s not properly documented, insurance companies may deny the claim or request refunds for past payments after a post-pay audit.
Accurate and complete documentation is the foundation of compliance, financial stability, and patient care. So, let’s explore how documentation influences reimbursement, common issues, and ways to ensure your records substantiate every claim.
Although not all records are subject to a pre- or post-payment review, insurance payers require clear and thorough documentation for all submitted claims. If the medical record doesn’t fully support the service billed, the claim may be denied—even if the service was medically necessary and properly performed.
Let’s explore the most common documentation issues that lead to lost reimbursements—and how to fix them.
One of the most common reasons for denials or recoupments is the lack of documentation that supports medical necessity. Payers need to see why a service was performed—not just that it was performed. A few examples include generic or vague notes (e.g., "OCT performed. Stable"), missing details about the diagnosis, disease severity, or treatment rationale, and a lack of an apparent connection between the patient’s condition and the billed service.
To avoid denials due to lack of documentation that supports the medical necessity includes documenting the reason for each diagnostic test or procedure and linking it to clinical findings, use precise language, e.g., instead of “Patient has AMD, proceed with anti-VEGF injection,” write “Patient with wet AMD shows increasing subretinal fluid on retina OCT, requiring anti-VEGF treatment.” Ensure that follow-up plans align with documented findings. If the patient is stable, justify why a test or treatment is still necessary.
When payers can see how everything connects, they’re more likely to approve claims for services.
Retina specialists rely heavily on diagnostic imaging, but billing for these tests requires more than just ordering and reviewing them. Some of the missing details can be a lack of a separate, written interpretation for diagnostic tests, such as retina OCT and fluorescein angiography, or, more commonly, there is no explanation of how test results impact treatment decisions. Another issue is the overuse of “normal” findings without sufficient clinical reasoning for ordering the test or understanding what “normal” means in relation to the patient's treatment plan.
To avoid this issue, be sure to include a standalone interpretation report, not simply referencing test results in the impression and plan. Explain the significance of findings, e.g., “OCT shows persistent intraretinal fluid; will proceed with anti-VEGF injection as planned.” Ensure tests are medically justified and not just ordered as routine practice.
Proper test documentation strengthens reimbursement and protects against payer audit denials and recoupments.
Using pull-forward or copy-paste in electronic health records (EHRs) can be efficient, but cloned notes must be edited to accurately reflect the actual patient visit; if they are not, it is a major red flag for payers. Some of the most common issues include copying and pasting the same exam note for multiple visits (including misspellings), failing to update the history, exam, or treatment plan to reflect the current visit, and chart notes that contradict previous entries, such as stating “ERM” when the ERM was surgically removed.
To sidestep this problem, edit and customize each note even when using templates, and update the findings to reflect the actual visit. If a treatment plan changes (which it often does), ensure that the reasoning behind the change is documented. Review notes before signing off—little errors and omissions can lead to significant claim denials.
Payers and auditors scrutinize for cloned notes and inconsistencies; they may demand repayments for multiple claims if these are found.
At the end of the day, strong documentation isn’t just about compliance - it directly impacts your practice’s financial health. By ensuring clear, complete, and timely records, your retina practice can reduce denials and payment delays, minimize audit risks, and improve efficiency and cash flow.
Clear, complete documentation helps keep your payments secure and reduces the likelihood of recoupment from payers.
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