A Step-by-Step Guide to Preparing Your Ophthalmology Practice for the New CMS Audits

The odds of a healthcare practice being audited took a tremendous jump this year. Proactive administrators are taking action now to make sure their practice is ready should auditors come knocking. 

In May 2025, the Centers for Medicare & Medicaid Services (CMS) announced “an aggressive strategy to enhance and accelerate audits” of Medicare Advantage plans. 

Since most Advantage plans cover at least some ophthalmology services, eyecare practices are among the providers likely to see an increase in audits. 

The purpose of an audit is to identify mistakes in how practices bill Medicare. Even if no errors are found, the audit itself is still stressful for practice owners and disruptive to practice staff. 

With the increased likelihood that your ophthalmology practice will be subject to a random audit, it pays to be proactive. With the right preparation, you can minimize the disruption auditors have on your operations. 

​​How CMS Audits Are Changing in 2025 

​More Audits 

​Backlog Clearance 

​Focus on RADV 

​Audits an Ophthalmology Practice May Face 

​RADV Audits in Ophthalmology 

​SMRC Audits in Ophthalmology 

​TPE Audits in Ophthalmology 

​The Ophthalmologist’s 2025 CMS Audit Preparation Checklist 

​Assign Roles and Responsibilities 

​Review Documentation and Coding Procedures 

​Optimize Your EHR 

​Organize Essential Records 

​Build an Internal Compliance Practice 

​What Triggers CMS to Audit an Ophthalmology Practice 

​Audit Trigger: High-Volume Procedures 

​Audit Trigger: Diagnostic Testing 

​Audit Trigger: Coding Errors 

​Audit Trigger: Medical Necessity​Audit Trigger: Bundled Services 

​Audit Trigger: Medical Necessity 

​Audit Trigger: Ophthalmology and Optometry Mixed Practice 

​Nextech Helps Make Practices Audit-Ready​ 

How CMS Audits Are Changing in 2025 

In 2025 and 2026, the healthcare industry can expect a surge in the number of CMS audits, as the agency expands its view and clears a backlog. While the reach of audits is widening, the focus remains narrow, specifically targeting Risk Adjustment Data Validation (RADV). 

More Audits 

There are over 500 Medicare Advantage plans. In recent years, CMS chose about 60 each year to spot audit. Within each plan, auditors would review about 35 records. 

According to the May announcement, annual audits will now be performed on all 500-plus Medicare Advantage plans. What’s more, CMS auditors will review anywhere from 35 to 200 records within each plan. 

Backlog Clearance 

In addition to exponentially increasing new audits, CMS intends to clear a backlog of audits going back to 2018. 

Through a combination of new technology and a hiring blitz of medical coders, the agency plans to have the backlog cleared within the first few months of 2026. 

That means practices could get hit by an audit asking for records from as much as seven years ago. Unprepared practices, particularly those that changed record-keeping systems within the past seven years, could find themselves in a bind. 

Focus on RADV 

There are a number of things an auditor could look for in a practice’s Medicare records. Specifically, CMS has said it is focusing on RADV. 

Auditors will be looking for any signs a diagnosis is inaccurate or unsupported by documentation. It’s crucial practices perform an immediate self-audit to make sure all clinical and diagnostic information is thoroughly documented and attached to patient records. 

A single source of truth for all your practice’s records. Check out Nextech’s platform specifically built for ophthalmology. 

Audits an Ophthalmology Practice May Face 

Ophthalmology practices could be hit with several kinds of Medicare audits. The most likely are audits for risk adjustment data validation (RADV), Supplemental Medical Review Contractor (SMRC), and Targeted Probe & Educate (TPE). 

RADV Audits in Ophthalmology 

RADV audits are intended to verify the accuracy of risk adjustment data submitted to Medicare Advantage plans. They are a bulwark against unscrupulous practices being reimbursed for phony diagnoses. 

What does this mean for your ophthalmology practice? It means auditors will scrutinize diagnosis documentation, particularly around chronic conditions such as glaucoma and macular degeneration. 

If the clinical documentation in a patient’s record doesn’t clearly support the diagnosis code submitted to Medicare, your practice might face penalties or be forced to pay back reimbursement. 

To protect your practice in the event of an RADV audit, use an ophthalmology-specific EHR as a central repository for all medical records. 

Nextech’s EHR uses smart tools like prompts and pre-populated forms to make record-keeping fast and easy. If you are audited, your practice will be able to quickly pull up detailed documentation justifying your diagnosis. 

SMRC Audits in Ophthalmology 

SMRC audits investigate potential overpayments to providers. While RADV audits are random, SMRC audits are triggered by unusual billing patterns and frequently misused diagnostic codes. 

In ophthalmology, SMRC audits are often set off by high-volume services like cataract surgery and diagnostic imaging. Because modifiers are a common source of coding errors, procedures involving modifiers are also frequently examined. 

Guard against SMRC penalties by using a platform that combines an EHR with powerful coding and billing tools. Nextech’s EHR and practice management platform helps practices reduce coding errors and defend necessary procedures. 

TPE Audits in Ophthalmology 

TPE is another kind of targeted audit. These are focused reviews targeting practices with consistent billing errors or high denial rates. 

If your practice is subject to a TPE audit, reviewers will request the records from a random selection of claims submitted during the audit period. 

For eyecare providers, the most common triggers for a TPE audit are improper modifier use, incorrect billing for bilateral procedures, and insufficient evidence of medical necessity. 

The best defense against a TPE audit is accurate coding practices to begin with. Intelligent tools in Nextech’s ophthalmology platform pre-fill forms and alert coders to any information that is missing, suspicious, or should be double-checked. 

Better together: When your EHR and practice management are on a single platform, clinical and business operations stay in sync. See how simple it is to manage a practice with Nextech. 

What Triggers CMS to Audit an Ophthalmology Practice 

Some CMS audits, such as RADV, are purportedly random. But many are triggered by a practice’s actions. 

Audits of ophthalmology practices may be triggered by: 

• high-volume procedures, 
• diagnostic testing, 
• coding errors, 
• bundled services, 
• questions of medical necessity, and 
• offering both ophthalmology and optometry in the same practice.

When preparing your practice to be audit-ready, you can reduce your risk of a targeted audit by prioritizing these high-risk areas. 

Audit Trigger: High-Volume Procedures 

A practice that performs a high volume of a single procedure, like cataract surgery or laser treatment, may draw the attention of CMS auditors. 

They’re looking for patterns that indicate procedures might be performed even when they’re not medically necessary. 

To counter this, train your staff on the importance of keeping detailed medical necessity records for all procedures, particularly those performed at a high volume. 

Staff performing the same procedure multiple times per day may have a tendency to become complacent when completing paperwork. Combat this by optimizing your EHR with automations and pre-filled templates that reduce manual data entry without sacrificing completeness. 

Audit Trigger: Diagnostic Testing 

CMS auditors are on the lookout for any unnecessary procedures a practice may use to inflate its bill. They want assurance that diagnostic testing like OCT and fundus photography is actually required. 

Just like in high-volume procedures, staff need to clearly document the reason for the test in the patient’s chart. Providers should indicate what they expect the test to find and how its results could affect the course of treatment. 

Audit Trigger: Coding Errors 

Ophthalmological coding is complex, and complicated by the fact that some procedures are coded bilaterally while others are assumed to be bilateral. 

Offer your medical coders regular opportunities for continuing education. Make sure they are all updated to the annual changes to ICD-10 and CPT codes. 

And provide them with smart coding tools like those found in Nextech’s intuitive platform to prevent coding errors that could bring on an audit.

Simplify your workflow, increase revenue, and maintain compliance with practice management software specifically created for eye care practices. 

Audit Trigger: Bundled Services 

Bundling services under a global period can be a great business move — but it can also attract unwanted attention from auditors. 

Bundling services – for example, including postoperative follow-up visits under reimbursement for cataract surgery – is usually seen as an efficiency move. 

But when staff don’t understand what is and is not billable under the global period, it can lead to incorrect billing for follow-up visits and tests. Make sure guidelines are explicit. 

Audit Trigger: Medical Necessity 

When reviewing records, auditors will look for detailed operative notes. It’s not enough for clinicians to note details of the procedure in the chart. Auditors will also want clear justification for the procedure, including symptoms, patient history, and exam findings. 

Smart tools in Nextech’s ophthalmology-specific EHR make it easy to record detailed information every step of the way. Our streamlined charting means providers can finish their documentation in minutes, not hours, without sacrificing completeness. 

Audit Trigger: Ophthalmology and Optometry Mixed Practice 

Combining ophthalmology and optometry under one roof is convenient for patients, but it can raise auditors’ eyebrows. 

They’ll want to be sure services are billed under the appropriate provider for accurate reimbursement. Set up charting and billing so each provider is clearly associated with the right records. 

The Ophthalmologist’s 2025 CMS Audit Preparation Checklist 

Get your practice audit ready by assigning team responsibilities, reviewing processes, optimizing your technology, organizing information, and building compliance into your daily workflows. 

1. Assign Roles and Responsibilities 

Why It Matters: Audits affect the entire practice. Taking a team approach to preparation prevents any one person from being overwhelmed and reduces the chance of things falling through the cracks. 

Common Mistake: Not setting a clear expectation across the practice that accurate record-keeping is everyone’s responsibility. 

What to Do: 

1. Train staff in every department to keep thorough, audit-ready records. Emphasize the importance of documentation in protecting the practice against an audit. 
2. Designate a member of your staff to be in charge of record-keeping compliance. Give them authority to make sure each department is following appropriate protocols. 
3. In the event the practice is audited, have a team in place to respond. The audit team should include a member from each department in the practice, such as IT, finance, and clinical operations.

2. Review Documentation and Coding Procedures

Why It Matters: The best defense against an audit are standard operating procedures that keep the practice in compliance. This avoids triggering targeted audits and enables you to respond to random audits with minimal disruption. 

Common Mistake: Settling for processes that are “good enough” for internal record keeping without considering how they will be perceived from the outside. 

What to Do:  

1. Conduct an internal audit. Put yourself in the shoes of an auditor and try to see your practice through their eyes. Look for incomplete documentation, inaccurate coding, or hard-to-find supporting information. 
2. Role-play a mock audit. Choose some staffers to play the part of auditors conducting an on-site visit. Gauge your staff’s preparedness by seeing how they respond to common audit questions.

3. Optimize Your EHR

Why It Matters: A robust EHR can be a powerful ally in your audit defense. This is where the documentation that protects you from penalties is completed and stored. 

Common Mistake: Using generic forms and complicated systems that lead staff to find workarounds in order to avoid the EHR. 

What to Do: 

1. Make the EHR a searchable central repository for all medical records, protected with appropriate encryption and authentication controls. 
2. Use ophthalmology-specific forms and templates so charting is quick, easy, and accurate. 
3. Create smooth, automated workflows from EHR to coding to billing, so the entire Medicare process is connected and easily accessible.

4. Organize Essential Records 

Why It Matters: In the event of an audit, you don’t want to be scrambling to find documents you’re sure exist — but that somehow weren’t included in the patient’s central file. 

Common Mistake: Organizing documents by department, such as clinical and billing, without a method to meaningfully connect all the records of a single patient or single diagnosis. 

What to Do: Centralize and connect all medical necessity records, signed consent forms, and billing reports into a single practice management system so that each department can find its records, and auditors can find a complete patient record. 

5. Build an Internal Compliance Practice 

Why It Matters: Your practice is busy, and audits can come at any time. Building compliance into your daily workflow keeps you always prepared. 

Common Mistake: Making an audit-preparedness check a one-time activity, then slipping into complacency. 

What to Do: Establish standard operating procedures to perform a quarterly review of charts and billing. Each quarter, document areas for improvement and any corrective actions taken. Maintain logs of these quarterly audits for both your internal records and to provide in the case of a Medicare audit. 

Spend time on patients, not paperwork, with Nextech’s intuitive and fully integrated ophthalmology platform. 

Nextech Helps Make Practices Audit-Ready 

You may not be able to completely avoid an audit. But with Nextech’s specialty-specific ophthalmology platform, you’ll be prepared if CMS comes knocking. 

Tools like built-in coding validation and automated reporting can prevent the errors that make practices a target for triggered audits. 

And detailed documentation, easily organized and retrievable, helps you defend yourself in a random spot check. 

With strategic preparation, rigorous protocols, and the right tools, you can face auditors with confidence. Request a demo and experience it for yourself.  

About the Author  

Courtney Tesvich is a registered nurse with more than 20 years in the healthcare field, 15 of which have been focused on quality improvements and regulatory compliance. She also holds an MBA and a master’s in jurisprudence in Health Law and Corporate Compliance. As VP of Regulatory and Compliance at Nextech, Courtney is responsible for ensuring that Nextech’s products meet government certification requirements and client needs related to the regulatory environment, as well as monitoring overall corporate compliance.