CODING Q&A

Alas, Even Minor Procedures Demand Scrupulous Documentation

SUZANNE L. CORCORAN, COE • KIRK A. MACK, COMT, CPC, CPMA, COE

Proper documentation for minor retinal procedures — specifically, intravitreal injections — is necessary. After an injection is performed, the operative report may be individually dictated by the physician, but many practices standardize this note since the procedures are so consistent. It is crucial this document contain all relevant information. Other record keeping is equally vital.

Q. What information is required in an operative report for an intravitreal injection?

A. Intravitreal injection (CPT code 67028) is the most common Medicare procedure in ophthalmology. There are a half dozen or more drugs used to treat a great many conditions. If we deal with only the more common of these, there are still a handful of FDA-approved on-label indications, and they vary by specific drug. As a result, we have multiple drugs and conditions being treated, although most of the time we may be able to use a standard document. Still, this is a surgical procedure, and payers expect to see a formal operative report.

Operative notes for an intravitreal injection may need all of the following; check yours against this list.

• Date of service

• Patient’s name and a second ID to ensure uniqueness

• Pre- and postoperative diagnoses (even if they are the same)

• Anesthesia (if any, including drops)

• Indications (to show medical necessity)

• Description of surgery — usually via a narrative that shows:

❍ The injected eye

❍ Prep methodology

❍ “Surgical time-out” verifying patient, eye, and procedure

❍ Any prosthetics, grafts, and supplies used (include gauge of needle used)

❍ Drug, dosage, lot, and serial numbers of medications

❍ Units used and units disposed or wasted, if applicable

❍ Site (eg, pars plana, superotemporal quadrant)

❍ Any complications (eg, elevated IOP, nonperfusion)

• Note that discharge instructions were given

• Signature of the surgeon

For efficiency, as well as to streamline the process, some offices incorporate an abbreviated preinjection evaluation with elements like vision, IOP, and pupils into their respective operative note. This, of course, is at the provider’s discretion.

Q. What other documentation do we need?

A. The injected medication is usually paid separately. Some medications are very expensive, others less so. All have high utilization, so they place huge cost burdens on our healthcare system. Additionally, the Office of the Inspector General (OIG) includes oversight of these medications in its annual Work Plan. With this amount of scrutiny, it’s easy to see why getting everything right is important.

Because of the high expense, it’s important to have good records of ordering, inventory-on-hand, injection logs, and billing. Your records should allow you to track specific vials or syringes to a specific patient and date of service in order to facilitate reconciling those vials/syringes with purchase invoices and claims submitted to payers if they should be required later.

Q. How do we track the medications?

A. Mark each lot, serial number, and other specific identifying number for each vial and organize your notes so you can track those numbers to individual eyes. That means having an accurate injection log and process. If your practice has multiple offices, be sure this is noted in your master log or keep separate logs for each site.

In most offices, keeping the log accurate and up to date is the responsibility of the personnel involved with the injections. Of particular note, you might need the log if an error turns up, or worse, an allegation from a payer that might be related (directly or indirectly) to poor record keeping. You will also need this information should there be a recall or safety problem with the drug itself.

Keep your purchase records for these drugs to prove that you received and paid for the medication. Reconcile these on a regular basis against your injection log. Investigate all discrepancies; matches must be perfect. Commercial programs can automate this record keeping process or you can do it on your own; the important part is that you actually do it.

Q. How should we address complementary vials?

A. Some vials are provided by manufacturers at no charge; these are not billable to any payer since you incurred no cost. You still need these to appear in your op notes, logs, and acquisition records to be able to reconcile properly.

Q. What else do we need to consider?

A. To ensure a proper dose, manufacturers place more in the vial than you actually need; this is known as “overfill.” Your chart or operative note should demonstrate that the vial has not been split or used on multiple patients by making a note of how you disposed of the extra. The temptation is huge to want to use this overfill; it’s against our nature to waste expensive product. Consider adding language to your op note to stress the importance of following that guideline. In their FDA-approved information for providers, manufacturers clearly note that each vial is for a single eye and that any unused product should be discarded.^1,2

Having good records and documentation is most important if you need to support any claims (civil, regulatory, and monetary) against your practice in the future. Review the documents you have, make changes where necessary, and don’t forget to periodically review or revise them. RP

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