Ophthalmology and Optometry Coding Alert
Base Injectable Drug Documentation on This Checklist
Question: When our physicians treat a patient via a drug injection, what should we be sure they include in their documentation? Where’s a good place to find this information? Maryland Subscriber Answer: When your ophthalmologist administers a drug injection, evaluate their chart documentation to confirm all necessary requirements are completed per payer guidelines. Clip and save this checklist to use as a guide and modify it, as needed, based on payer guidelines: For services provided to Medicare beneficiaries, reference the current Medicare local coverage determination, which can be found at www.aao.org/lcds. Commercial, Medicare Advantage, and Medicaid payers may have policies on their websites. Tip: For retinal coding resources, including a comprehensive intravitreal injection documentation checklist and the AAO’s table of common retina drugs, go to aao.org/retinapm, Woodke advises.
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