Optometry billing and coding is not easy.
It is one of the most challenging things to learn, for both newly graduated optometrists, along with ODs who have been in business a very long time!
In order to help, we asked billing and coding expert Eric Botts, OD to answer these 22 common optometry billing and coding questions!
1. What are the most common mistakes providers make when it comes to billing and coding?
- Not being credentialed correctly for every carrier they submit claims to, resulting in denied claims
- Incorrect use of modifiers
- Under-coding the exam because the documentation is deserving of a higher office visit code
- Not properly documenting supplementary tests like visual field, fundus photos and OCT
2. Can you be penalized for under-billing?
You’re not likely to receive penalties by most insurance carriers, but you will consistently lose fee revenue for every under-coded exam. The average doctor may be losing an average of $30 per claim for under coding their exams.
3. Can you use a 92 code in medical management more than once a year? Is there an advantage to using these this code vs 99 codes?
I recommend only one 92004/92014 per year however you may perform multiple 92012 during the year
4. Is it common for insurances to pay for Medically Necessary Contact Lenses?
Many medical insurance carriers do not reimburse for medically necessary contact lenses; therefore, I suggest you inform the patient they will be financially liable for the lenses ahead of time. You can contact each insurance company to inquire about reimbursements, but it is better to set expectations ahead of time.
5. In what situations is it appropriate to bill for left and right lids separately?
Any unilateral procedure will require a modifier for either the lid (E1, E2, E3, E4) or RT/LT. Examples are conjunctival foreign body removal 65205, epilation 67820, punctual occlusion 68761.
6. Is there a code you can utilize to bill after hours visits?
Most carriers do not pay an additional fee for after hours service CPT code 99050. Medicare considers it a bundled service for office visits.
7. What are the different modifiers and when do they need to be used?
- RT – right eye
- LT – left eye
- E1 – upper left eyelid
- E2 – lower left eyelid
- E3 – upper right eyelid
- E4 – lower right eyelid
- 24 – unrelated E/M by same doctor during postoperative period
- 25 – Separately identifiable E/M service provided by the same doctor on the same day as another procedure
- 51 – Multiple procedures performed on the same day during the same encounter
- 59 – Distinct procedure service identifies procedures/services not normally reported together but appropriately billed under the circumstances
- 79 – unrelated procedures or service by same doctor during the postoperative period. Example: perform postoperative care for cataract on second eye during the postoperative period for the first eye
8. Can you bill for fundus photography if you are monitoring a condition, even if that condition is not showing any change? Or can you only bill fundus photography if there is documented change?
In the case of high risk medication use like Plaquenil, a baseline pathology-free retina photo is allowed. In progressive disease like diabetic retinopathy or glaucoma, then a repeated photo requires documentation as to why the photo is medically necessary — which often an be defined as demonstrating change from previous photos.
9. How do you appropriately bill and code for foreign body removal? Can you use the same code for the procedure and office visit? Or do they require different diagnosis codes?
Only bill for foreign body removal 65222 or office visit but not both on the same day. Only exception is if the office visit is necessary for another completely separate diagnosis like a glaucoma follow up or if it is necessary to look for a penetrating foreign body that possibly penetrated cornea/sclera and into the retina/vitreous.
10. What would be an example of a situation in which billing a 99 – level 4 or 5 code would be appropriate? We are often cautioned against using these codes.
If you meet the required level of history, performed and documented exam elements and medical decision-making then I see no reason not to bill 99204/99215. The same goes for 99205/99215 with the exception that I only bill a -5 level exam when the medical-decision making level is high which typically means the patient is presenting with a minimum of three new problems that I have not diagnosed or treated previously.
11. What are the most common triggers of an audit?
- Over-use of 99205/99215
- Use the same code for every exam
- Order supplementary test without medical necessity
- Billing for care not provided
- Significant variation of E/M code percentages from area doctors
12. What are the main reasons practices and ECPs fail an audit?
Insufficient documentation for the service provided. Unless you write it in the patient file, you receive no credit for performing the test.
13. What are the consequences of an audit if you fail?
If the audit is failed due to mistakes in billing, the provider will have to refund any insurance overpayments found and you might open yourself up to more audits in the future. If the provider fails an audit due to fraud, they are open to criminal investigations which can lead to large fines and potential jail time.
14. How many times can you bill for OCT a year safely if you are treating a patient for glaucoma or macular degeneration?
Glaucoma is dependent on diagnosis: suspect or mild glaucomatous damage is 1 OCT every 12 months, moderate glaucomatous damage 2 OCTs every 12 months and severe glaucomatous damage cannot be billed for OCT because there is no progression to be measured at end-stage glaucoma.
15. What is the best/proper way to code Plaquenil exams for patients with autoimmune disease?
Use three diagnosis codes including one identifying systemic disease (rheumatoid arthritis M06.09), one for high risk med Z79.899, and if toxic retinopathy is present then also use the anti-malarial drug code T37.2X5A. You may perform and bill for supplementary tests like photos as a baseline even if no pathology is present. This is the exception to the rule for billing fundus photos, as typically pathology is necessary to bill fundus photos.
16. Is a DFE necessary to bill certain procedure codes? Or can you bill so long as you examine the posterior pole with other methods like ultra widefield imaging?
DFE is rarely a requirement for any level of 99xxx/92xxx office visit; however, some carriers may have DFE written into their policy for 99204/99214/92004/92014.
17. What is necessary to bill for insertion and removal of a bandage contact lens?
Most insurance carriers bundle the bandage contact lens with the other procedure being performed such as removal of corneal foreign body. For successful healing of the cornea, a better option today is to fit an amniotic membrane using CPT 65778. The office visit is bundled with the procedure so it can’t be billed separately. It reimburses over $1300 per procedure and the membranes cost between $150 -$900 each.
18. If a patient is under the care of another provider who is performing special testing regularly, can you still bill and code if you perform special testing in your office?
Yes, unless the patient’s insurance does not allow; for example, if it is an HMO that controls who patients can see.
19. Can you offer ultra widefield imaging as a screening test, but bill it if there is something medical that arises on testing?
I would not bill medically if the premise for the test was a screening test. Instead the next time the test is ordered it can be billed medically.
20. How do you bill appropriately for cataract surgery co-management?
Date of surgery must be used as service date, modifiers 55, RT or LT for first eye and add 79 for second eye if it is in Global period of first eye or surgery is performed within 90 days of first eye.
Surgeon and NPI should be on HCFA as referral Dr. Assumed care start and end date and # of days of care in box 19. It depends on the state, but the most common way to code is to have the surgeon’s name in box 17 and their NPI in 17b. The start date of the care goes in box 19. Referring to the surgery date, calculate the end date of the global period and list the days of the care. In box 24 for to and from date put the date of the surgery. Units depend on carrier and may be 1 or the number of days you provide co-management services. The cataract code and DX code used by the surgeon go on the claim. Add RT or LT with 55 and the 79 mod if it’s the second eye performed within 90 days of first surgery.
21. How do you bill appropriately for punctal plugs?
One line for each plug using the E modifiers. 25 mod goes with the 99 and 92014 exam codes.
To get paid the most only do two plugs in any patient encounter as you will be paid in full for the first one but only half for any other plugs on the same day.
68761 CPT E1 or corresponding Modifier with placement and 51 on the second plug or third and fourth if you choose to do all 4 on same day. If you do two and two you must wait 10 days in between procedures as there is a 10 day global period.
22. Are there any different codes if you do home health or nursing home care?
Yes, there are different codes you use for place of service as well as office visits. However you may use the 99xxx and 92xxx codes, as they may reimburse better than the 99 codes specific for domiciliary, rest home or custodial care services. These facility specific codes range from 99324-99328, 99307-99310 and 99334-99337. Place of service will be different than the 11 typically used for office visits, skilled nursing facility is 31, nursing facility is 42 and custodial care is 33.