• Payer Documentation Requirements When Injecting Eylea


    What are the payer documentation requirements when injecting Eylea?
    From the Academy's Audit Success Toolkit

    Novitas, a Medicare administrative contractor (MAC), is sending Target, Probe and Educate (TPE) audit letters to high-volume users of Eylea in these areas and states:

    • Jurisdiction L - Delaware, Maryland, New Jersey, Pennsylvania and the Washington, D.C., metropolitan area (including Arlington and Fairfax counties in Virginia and the city of Alexandria, Va.)
    • Jurisdiction H - Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma and Texas

    Members report being required to submit up to 40 medical records of patients being treated with Eylea for wet macular degeneration.
    If you get an audit letter, the Academy's coding and reimbursement team suggests reading the following resources to help you respond.

    Academy Resources

    • Visit aao.org/audits to learn more about TPE audits.
    • Get details of your local coverage determination (LCD) requirements for Eylea at aao.org/lcds.
    • Use this anti-VEGF drug documentation checklist.
      • Confirm there are 28 days between injections in the same eye.
      • Record surgical order which includes the drug name, dosage and indication (diagnosis) with physician signature.
      • Assess visual acuity.
      • Make sure you record the chief complaint and elements to the history of the present illness (HPI).
      • For new patients, document why the specific drug was chosen.
      • For established patients, document at each visit why you are keeping the patient on the drug and how the patient is responding to it.
      • Document how much of the drug was injected.
      • Document how much of the drug was wasted. If it was less than one unit, include language similar to “residual medication discarded.” (Remember, never share a vial between both eyes. Correct billing is one vial per eye.)
      • Ensure that the diagnosis is a covered benefit by the particular payer. If it's not a covered diagnosis, the patient is responsible for the injection and drug costs.
      • Document that the patient desires surgery.
      • Obtain informed consent if it's the first injection or if there's a change in medication or eye.
      • Maintain legible medication administration records.