Sep 23, 2024
Apr 3, 2025
Written By Elizabeth Cifers
Proper medical documentation is the heart and soul of compliance and reimbursement at your retina practice. “Not documented, not done” is the auditor’s rule of thumb.
Think about when a patient tries to recall past symptoms, “It was on Thursday—no, wait, it was last week.” You factor in their comments as best as possible, but we all know memories are fuzzy and are, at times, unreliable. That’s why chart documentation should be done at the time of the service —not days (or weeks or months) later—to support proper billing.
The golden rule of medical documentation is this: document. Period. That being said, clarifying what “proper” documentation looks like is important. Below is a quick reference guide for proper medical documentation at your retina practice:
1. Not documented, not done. If the service or procedure isn’t in the chart documentation—whatever it may be—it might as well have not occurred; that is how the insurance payer will see it. While a payer may pay for a service initially, if there is a medical record review or an audit, it is unlikely that your retina practice will keep any payment for something that has not been documented.
2. Medical documentation should be clear. Clarity is key. There’s no point in getting fancy or creative with your documentation. Who has the time, anyway? Simply state the necessary information in plain English. Which leads to our next tip:
3. Long documentation ≠, good documentation. Medical documentation doesn’t need to be verbose. What’s important is that the necessary information is included (more on that in 4, 5, 6, & 7).
4. Support the exam findings. The exam findings should be listed in the documentation. This will help support the diagnosis(es) listed and billed.
5. Support the test findings. Diagnostic test findings should also be in the documentation. Most retina testing requires an interpretation and report.
6. Support the diagnosis(es). The diagnosis(es) should also be listed for proper documentation. Remember to tie the diagnosis to the exam and other findings. Do not include diagnoses that are resolved or no longer exist.
7. List a chief complaint. Every office visit and procedure should have a chief complaint. Why is the patient there? Sometimes, there can be several complaints. Be sure to address each complaint stated.
If proper payment is a significant focus of your retina practice—as it should be—ensuring proper medical documentation ought to be a central strategy. The compliance of your retina practice hangs on the accuracy and completeness of your documentation.
One of the best ways to correct documentation errors is to conduct routine chart audits, at least annually. Partnering with an experienced auditor who can hold your retina practice accountable to proper auditing standards will likely produce more valuable results than if you were to audit on your own. Consultant Elizabeth Cifers, MBA, MSW, CHC, CPC, has decades of medical documentation expertise and retina-specific experience, including 13 years at a retina practice and a role at a leading eye care consulting firm. She excels at auditing and would be happy to take a look at your charts. If you’re ready to get started or strongly considering a chart audit for your retina practice, schedule a free consultation with Elizabeth here.
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