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  • How to Ensure Your Recordkeeping for Injections Is Complete

    If your ophthalmic practice performs injections, including anti-vascular endothelial growth factor (VEGF) injections, then it’s not a matter of if you’ll experience a payer audit, but when. Make sure your billing records are complete.

    Medicare has multiple audits, including Targeted Probe and Educate (TPE) prepayment audits and Recovery Audits. Even the Office of Inspector General requests records for exams, testing services and operative reports. 

    Among the targeted drugs are Avastin, Lucentis and Eylea. This is likely because claims using CPT code 67028-Intravitreal injection were submitted more than 3.4 million times in 2017, according to the latest utilization data. 

    With federal scrutiny from Medicare and other agencies, it’s wise to make sure you meet the payer and auditor documentation requirements so you’re prepared and covered when audit requests arrive.

    Make sure your exam documentation includes:

    • Confirmation of at least 28 days (per label requirements) between injections in the same eye
    • Order for injection, including the drug name, dosage and indication (diagnosis)
    • Chief complaint and elements to the history of present illness (HPI) are listed and legible
    • Visual acuity 

    For new patients, it’s best to indicate why a specific drug was chosen because auditors’ checklists include this language. Supporting documentation for established patients should include the reason the patient is staying on a specific drug and how they’re responding. If the drug changes, indicate the reason.

    Testing services should include a documented order, if performed by ancillary staff. The physician interpretation should be documented in a timely fashion. Be sure to comply with payer guidelines because Medicare Administrative Contractors (MACs) with policies for Retina Optical Coherence Tomography (OCT) indicate they are often performed monthly with active retinal disease management.

    Medicare does not cover standing orders for OCT. It emphasizes the “active” part of retinal disease management, and if the patient is coming in for a followup appointment more than monthly, it may not be covered. An OCT order during followup appointment to evaluate the other eye would still not be covered because OCT is a bilateral service. But if after a subsequent visit a physician orders an OCT, it would be covered.

    This may impact the frequency of performing tests for one or both eyes. Practices sometimes receive denials when another physician also orders an OCT. Frequency is based on a per patient rule, not per physician. That means the payer does not expect to see this test billed more than 12 times in the previous year. Some Medicare MACs may only cover 13 OCTs in the last 12 months for each patient. 

    It is also important to maintain an accurate inventory log. Auditors will compare your inventory log to your documentation.

    Procedure note documentation requirements include:

    • Diagnosis or indication for injection
    • Site of injection, eye(s) treated
    • Medication name, how much was injected (in milligrams and volume in milliliters) and lot number
    • How much of a drug is wasted. If it’s less than 1 unit, should state language like “residual medication less than 1 unit discarded.” For example, HCPCS code J0178 indicates Injection, aflibercept, 1 mg. If less than 1 mg is left, document the language above.  
    • Route of administration
    • Physician signature, legible or secure if electronic
    • Usage of a covered diagnosis by the payer. If the diagnosis is not included in the payer policy, the patient is responsible for the injection and drug costs.
    • Documentation that the patient desires treatment
    • Informed consent on file of first injection and/or change in medication or eye
    • For initial treatment of Avastin, a consent stating off-label use is completed
    • Maintenance of legible medication administration records

    What to Do Next: Review Current Documentation

    How does your current documentation compare to what the payers are requesting? You should perform an internal audit to see where you may have vulnerabilities. Common errors include billing for one drug, yet another is listed on your inventory log. This could be a potential loss of over $1,000.  

    Another common error is the incorrect eye is documented on an inventory log versus a chart. Take action to correct before you receive a request for recoupment.

    Where Can More Information on Audits Be Found?

    Each MAC lists areas of focus for chart audits. This content, along with resources to prepare, is available at A checklist of items will be included in an audit request. Be sure to verify the date of exams you’re providing and match the items requested. If you fail to comply with requested information or provide in the time frame indicated, you will automatically fail the audit. 

    Also make sure to review your Medicare payer policies and articles on You may need to access an archived policy depending on the date range of the service requested and your current policies effective dates. Commercial policies may be found on the individual websites.

    The Profitable Retina Practice Series provides continuing guidance on management of a retina practice and medication inventory management and the electronic versions are now complimentary for AAOE members. 

    About the authors: Jenny Edgar, CPC, CPCO, OCS, OCSR, is a manager in the Academy’s Coding and Reimbursement office. She also is a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Joy Woodke, COE, OCS, OCSR,  is a coding and practice management executive with the Academy.