Reducing Audit Risk in Ophthalmology and Optometry

Eye services remain a consistent area of focus for the OIG, with recent audit activity highlighting patterns that can quickly turn into repayment exposure: E/M services billed on the same day as intravitreal injections, high-level nursing facility E/M services billed by optometrists, and diagnostic tests billed together (or too frequently) without clear medical necessity.

Why this matters right now

OIG’s approach across these reviews is consistent: start with data trends (high-volume patterns, outliers, unusual code selection), then validate with documentation and medical necessity. Even when services are clinically appropriate, compliance risk increases when documentation doesn’t clearly support:

• Modifier use (especially modifier 25 and modifiers like XU/59)
• Separately identifiable services vs. work “included” in a procedure
• Medical necessity expectations (including frequency limits tied to payer policy/LCDs)

Here are the most important takeaways from our Eye Care Compliance Under OIG Scrutiny webinar and shares practical actions compliance, coding, auditing, and revenue integrity teams can take now to stay ahead of risk.

1) Intravitreal injections + E/M on the same day (Modifier 25)

One of the strongest themes in recent OIG work is the frequency of E/M services billed with modifier 25 on the same day as intravitreal injections. OIG views this combination as a potential indicator that claims edits are being bypassed without adequate support.

Key takeaway: It’s not that E/M on the same day is always wrong, it’s that it must be significant and separately identifiable, and the record must make that clear.

What OIG is looking for:

Practical examples:

More defensible scenario:
An exam leads to identification and management of a separate condition (e.g., issues in the fellow eye), with patient education, monitoring guidance, risk-factor counseling, and a distinct plan.

Higher-risk scenario:
Documentation shows the visit was primarily to evaluate the same condition and “decide to treat” with an injection, work OIG views as generally included in the procedure payment.

What to do now:

• Audit same-day injection + E/M claims and stratify by provider, location, payer, and frequency
• Create documentation expectations for when modifier 25 is used (separate diagnosis + separate plan)
• Train clinicians on how to document why the E/M is separately identifiable without “note bloat”

2) Optometry E/M in skilled nursing facilities (high-level codes as an outlier signal)

OIG also reviewed optometry services in nursing facilities, focusing on high-level subsequent nursing facility care E/M codes (notably higher-complexity codes).

Key takeaway: OIG used analytics to find patterns that “don’t look typical,” then drilled down quickly to the biggest outliers.

What OIG is looking for:

• High-level E/M selection that doesn’t match documented severity/complexity
• Notes reflecting routine issues (e.g., dry/itchy eyes) paired with codes intended for much higher complexity
• Scheduling patterns suggesting “routine visits” rather than acute needs
• Run internal reports for SNF E/M levels by provider and compare to peers
• Target reviews to the top billers/outliers first (highest exposure, fastest insight)
• Reinforce E/M leveling standards (time vs. medical decision-making) and ensure the note supports the chosen method

What to do now:

• Run internal reports for SNF E/M levels by provider and compare to peers
• Target reviews to the top billers/outliers first (highest exposure, fastest insight)
• Reinforce E/M leveling standards (time vs. medical decision-making) and ensure the note supports the chosen method

3) Procedures + modifiers + medical necessity (XU/59, mutually exclusive testing, frequency limits)

The third theme is where many organizations get surprised: an audit may start by reviewing one issue (like modifier 25) but expand into other services billed the same day, especially diagnostic testing and modifier use.

Key takeaway: Even when an organization “generally meets” requirements on one area, OIG may still identify risk if documentation doesn’t support medical necessity, frequency, or distinct procedural service modifiers.

Common risk areas highlighted:

• Fundus photography + OCT/SCODI billed together when policy treats them as generally mutually exclusive
• XU/59 modifiers used to bypass edits without clear documentation that services were distinct and necessary
• Frequency limits (often tied to LCDs/payer policies) not followed or not justified in the record
• For commonly paired tests, build a “must-have” documentation checklist:
  • Why both tests were needed today
  • How each test changed management
  • Clinical condition(s) that justify billing both (when applicable)
• Monitor frequency for high-volume testing and flag exceptions for review
• Align coding, clinical operations, and compliance on the difference between:
  • “We did it” vs. “It’s billable under policy”

What to do now:

• For commonly paired tests, build a “must-have” documentation checklist:
  • Why both tests were needed today
  • How each test changed management
  • Clinical condition(s) that justify billing both (when applicable)
• Monitor frequency for high-volume testing and flag exceptions for review
• Align coding, clinical operations, and compliance on the difference between:
  • “We did it” vs. “It’s billable under policy”

Fast self-audit checklist (use this as your starting point)

If you only do a quick internal check this month, focus on these:

1. Injection + E/M + modifier 25: Does the record show a separate problem and separate plan?
2. High-level SNF E/M: Are the highest-level codes supported by MDM/time and clinical severity?
3. Mutually exclusive testing pairs: Is documentation strong enough to justify modifiers and necessity?
4. Frequency: Are repeat tests inside common policy limits—and if so, is the rationale documented?

How to operationalize this with connected oversight:

These issues are easiest to manage when audit and compliance teams can see trends early and respond before patterns become exposure.

• Audit Manager+ can help teams pull billing data, track audits, apply standardized checklists, and QA reviewer work across multiple auditors.
• Compliance Manager can help translate audit findings into corrective actions, education, follow-up monitoring, and defensible documentation workflows.

When Audit Manager+ and Compliance Manager work together, audit results become an early warning system, turning compliance into proactive prevention instead of reactive cleanup.

To download this blog post as a pdf, fill out the form below