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Retinal surgery is often needed to prevent permanent vision loss. The nature of retinal disease means retinal surgery is often urgent or, in the mind of the surgeon and patient, nonelective.
However, “urgent” doesn’t mean you can neglect documenting medical necessity. Payers expect your documentation to support medical necessity as well as the patient’s informed consent for treatment. It’s important you be familiar with any payer policies for the procedures you perform and apply the same documentation principles to procedures that don’t have policies.
Making sense of policies
You’re no doubt aware that payer policies vary widely. The Centers for Medicare and Medicaid Services develops National Coverage Determinations (NCDs). Individual Medicare Administrative Contractors (MAC) have Local Coverage Determinations (LCDs). And commercial carriers develop policies that may be vaguely worded or that deem newer procedures “experimental.”
Some, like the Medicare NCD for vitrectomy,1 lack specific documentation requirements. The policy simply lists covered diagnoses and states the need to document medical necessity.
Commercial carriers can be even more challenging. Although a policy may seem quite extensive, the opening salvo can be unnerving, as you can see in this example, including the asterisks and all caps, from Blue Cross/Blue Shield of Illinois’ policy for photodynamic therapy (PDT) for choroidal neovascularization: “Coverage: *CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*”2
Since you won’t be able to investigate every insurance contract your patients may have, the importance of standardized, comprehensive documentation is clear.
There’s some guidance if one reviews a policy like the one from CGS Administrators, the MAC for Region J15. CGS provides a local coverage policy, “Pan Retinal Photocoagulation (PRP) Documentation Requirements,” that provides a good starting point to standardize your surgical documentation.3 The policy states:
The patient’s medical record should include but is not limited to:
- The assessment of the patient by the ordering provider as it relates to the complaint (emphasis added) of the patient for that visit.
- Relevant medical history.
- Results of pertinent tests/procedures.
- Signed and dated office visit record/operative report.
Patient complaint is key
You might think the patient complaint is irrelevant for a procedure such as PRP, retinal cryopexy or vitrectomy. However, all payers require a chief complaint to support surgery. In the case of PRP, the chief complaint may be “poor vision for all activities due to episodic vitreous hemorrhaging, right eye.” If the patient has no subjective visual complaints, it’s important to document the severity of the disease, including likelihood of vision loss, due to the retinal condition.
The patient’s medical history should be relevant to the procedure under consideration. Thus, poorly controlled diabetes is significant for diabetic retinopathy; anticoagulation therapy may be relevant in determining the need to move forward with subretinal hemorrhage evacuation.
Recall that the new Evaluation and Management (E/M) exam code rules don’t require a full review of systems. (Avoid box-checking!) Conversely, the eye codes require a relevant medical history. Obtaining a concise, useful history will streamline the work-up, declutter your documentation and meet the payer policy for the majority of surgeries you perform.
Also, the impact of testing is important for determining medical necessity for surgery. Any ophthalmic imaging that demonstrates a worsening disease state or prior procedures that were ineffective or only partially effective will support additional treatments or surgery.
Use a checklist
Both simple and complex tasks, such as documenting a surgical admit, can benefit from a checklist. For your surgical admits, a documentation checklist should include:
- Patient chief complaint with history of present illness.
- Review of medical history relevant to the exam.
- Clear patient-stated effect on activities of daily living when there’s a decrease in vision or if the surgery is elective (e.g., epiretinal membrane peel, vitrectomy for floaters).
- Assessment clearly stating the impact of the disease on vision (e.g., “the vitreous hemorrhage is the cause of decreased vision OD”) if there’s:
- more than one reason for decreased vision, a clear indication justifying the surgery under consideration; or
- no current impact on vision (e.g., retinal hole or tear; neovascularization), which is the probable course if the disease isn’t treated.
- Clearly documented discussion of the specific risks, benefits and alternative treatments, including no treatment (a consent form doesn’t replace the surgeon-
patient discussion).
- If applicable, the rationale for scheduling urgent or emergent surgery (e.g., “recommend surgery within 24 hours to prevent further retinal detachment and potential loss of central vision”).
Bear in mind that the insurance company paying the claim doesn’t share your expertise in retinal disease and surgery. Weak documentation can result in a payer considering a surgery unnecessary. The stronger your documentation, the less likely you’ll suffer retractions. Remember, as with all areas of chart documentation, if you didn’t write it down, you didn’t do it. RS
REFERENCES
1. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) Vitrectomy. Publication number 100-3; Manual section number 80.11. https://www.cms.gov/medicare-coverage-database/view/ncd.
2. Blue Cross Blue Shield of Illinois. Medical Policies: Photodynamic therapy (PDT) for choroidal neovascularization (CNV). Number:OTH903.015 http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=kx37biep&corpEntCd=IL1 Effective January 1, 2022.
3. Centers for Medicare & Medicaid Services. Medicare Coverage Determination: Billing and Coding: PANRETINAL (Scatter) Laser Photocoagulation. Article ID A56594. https://www.cms.gov/medicare-coverage-database/view/article.
