Keeping proper notes can prevent future hassles

Proper operative note documents for minor retinal procedures—specifically, intravitreal injections are necessary. Once the need for an injection is determined, the technician or medical assistant is charged with pulling a “standard” operative note. It is crucial this document contains all relevant information.

Operative Notes Checklist

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 only a handful of FDA-approved on-label indications and they vary by specific drug. The newest drug is for use with vitreomacular traction, but only one has that approval. As a result, we have multiple drugs and conditions being treated, but most of the time we may be able to use a more standard document.

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

■ Date of service (injection)

■ Patient’s name and “second ID” to ensure uniqueness

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

■ Anesthesia (if any)

■ Indications for injection (shows the medical necessity)

■ Description of surgery—usually a narrative that shows:

● Prep methodology

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

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

● Drug, dosage and lot and serial numbers of medications

● Units used and “disposed or wasted,” if applicable

● Site (e.g., pars plana, supero-temporal quadrant)

■ Any complications (e.g. elevated IOP, non-perfusion)

■ Note that:

● Discharge instructions were given

● Drug not used is disposed

■ Signature of the surgeon

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

Record Keeping

Because of the high expense to the payer, it’s important to have good records of ordering, inventory-on-hand, injection logs, and billing. That may not part of an operative note, but it is vital to a practice’s record-keeping procedure. Neither the payer nor your office wants to pay for things they shouldn’t. You don’t want to be the one who “can’t locate” a $4,000 vial! Your records should allow you to track specific vials and syringes to a specific patient and date to facilitate reconciling those vials with purchase invoices and claims submitted to payers if it should be required later.

“Good coding” (and documentation) to all of you! — Paul OP

Mr. Larson is an associate consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.