Guide to Coding and Billing in Optometry

If you are new to the world of coding and billing in Optometry, I am sure you are wondering where to begin.

Unfortunately not much is covered during your years learning optometry so as soon as you graduate you have to begin catching up to your more experienced colleagues.

Learning coding and billing in optometry for ocular disease is best done by learning from other optometrists. There are a number of coding experts to choose from but I must emphasize many of the courses offered are geared towards the broad field of medicine and a 6-hour course that covers multiple disciplines of medicine may spend as little 30 minutes on ocular disease while covering cardiology, oncology, and primary care medicine.

ICD-10 codes are very specific for each specialty and will require you to familiarize yourself with hundreds and potentially thousands of diagnosis codes. One website that will assist you with learning diagnosis codes is Here you can look up any and all diagnosis codes you may need to code the ocular exam as it is critical that you accurately choose the most specific code available for every patient encounter.

Another convenient tool for learning coding and billing in optometry is the coding booklet I put together that can be found on Amazon or at If you are willing to do your own research and want to learn more about how Medicare works then I suggest you visit the website where you can learn about the fee schedule, MIPS incentive program and modifiers as well as reviewing the 1997 Evaluation/Management Guidelines.

One of the most frequently made mistakes in coding and billing in optometry is to submit a medical exam to a routine insurance carrier typically resulting in a much lower reimbursement.

It is important to understand the difference between medical and routine exams to ensure you receive full reimbursement for your services. How to distinguish the difference between the two exams begins with knowing there are more similarities than differences. The chief complaint drives the exam but don’t assume that every patient complaining of blurry vision is a refractive issue.

Often, blurry vision has an underlying medical condition resulting in a medical ocular exam being performed instead of a routine exam being submitted to a vision plan. The case history performed on a new patient should not vary for a medical exam versus a routine exam since it is performed before you see the patient and the type of exam has not been established yet. The elements of the exam are similar between medical and routine exams with one major difference.

When performing a medical exam you must choose the exam elements necessary to diagnose and treat the patient and perform only those tests. Many doctors will perform the same exam elements as part of a routine exam on every patient which is not acceptable for a medical ocular exam because it may incorrectly raise the level of exam being coded for visit. The decision-making process is also different for a medical exam versus a routine exam since routine/refractive exam requires little or no medical decision-making and a medical exam typically includes either low or moderate medical decision-making.

Another frequently made mistake in coding and billing in optometry is using modifiers incorrectly resulting in denied claims.

Modifiers are a means to more accurately describe a service however when incorrectly used lead to a large percentage of denied medical claims. Frequently use modifiers for ocular exams include RT/LT for right and left eye/lid as well as E1-E4 modifiers to differentiate right and left as well as inferior and superior lids. -24 modifier is used when a doctor performs an office visit during the global period of an unrelated procedure. An example is when a patient previously had cataract surgery performed within the past 90 days and presents with an unrelated ocular issue in the other eye.

In order to be reimbursed for the office visit, you must add a -24 modifier to the office visit when submitting a claim to the insurance carrier. -25 modifier is used when performing two separate and unrelated procedures on the same day.  -55 modifier is necessary when you co-manage a surgical procedure with a surgeon and only perform the post-op care. In addition, if you are performing post-op care on a patient who had both eyes surgically repaired you must use a -79 modifier when coding the second eye to ensure reimbursement is not denied as a duplicate procedure.

The third most commonly made error involves improper credentialing and/or submitting claims prior to being fully credentialed for an insurance panel.

It is critical before credentialing that you decide if you will be a sole proprietor or corporation and I strongly encourage you to seek proper legal advice from an attorney before beginning the credentialing process.

It is equally important that you not see patients on a particular plan until your application has been processed and approved. In the case of Medicare where you can backdate claims, you must first establish a starting date prior to seeing Medicare patients. The starting date is typically the date they begin processing your application.

When it comes to insurance reimbursement several steps are required before a doctor will be paid.

It starts with proper documentation of your exam, if it is not documented then you did not do it. Therefore, document every test you do including proper documentation of all supplementary test that you perform. Coding a patient encounter should be done by the doctor as the doctor should be in the best position to properly code all procedures and office visits as well as the diagnosis codes and modifiers. Submitting the claim may fall on a billing specialist employed directly in your office or may be outsourced to a well-trained billing service that is well educated on the specific codes required for optometric claims.

Choosing the right service for coding and billing in optometry is critical to ensuring continuous cash flow for your practice. How well your insurance claims are processed determines how financially strong your practice will be. Your billing specialist should be able to submit all claims in a timely and efficient manner and should work any existing accounts receivables to ensure your 90 days and older AR is approximately 20% of total AR amount. You will always have AR older than 90 days due to some insurance carriers taking longer to reimburse claims as well as denied claims that need to be researched and resubmitted, additionally some claims need to be submitted to a secondary carrier after the primary carrier has processed the claim.

One last cause for a higher AR is waiting on patient payments after the claim was processed and you bill the patient for a balance that is due. To avoid unnecessary patient billings always collect co-pays and fees that are applied towards the deductible the same day as the exam. It is much more efficient to collect from the patient in your office than waiting on them to send a payment in response to a bill sent by your office.

Choosing the right insurance panels to be a provider for is extremely important for increasing your practice profitability.

This should not be made until you do some research on who are the largest employers in your community as well as what are the reimbursements on the different vision plans you may choose to participate with.

Medicare has over 50 million recipients today and is likely to increase to 80 million by 2030. I recommend applying to be a participating Medicare provider that accepts assignment because these patients are in most every community nationwide and Medicare credentials all doctors that apply whereas some carriers will close their panels or limit the number of OD’s that they credential.  Medicaid is helpful if you are not as busy because it is one of the fastest growing insured populations but has a lower reimbursement then Medicare in all states and can be significantly lower in certain states.

Commercial carriers like BCBS, CIGNA and AETNA are typically better-paying plans but more difficult to credential for. Occasionally a commercial medical carrier will partner with a routine vision plan and may require you to participate in a particular routine plan to credential with the medical carrier. Keep in mind that different states and different carriers have different rules so do your research before you make any decisions on which panels to credential with.

The final topic to discuss when it comes to coding and billing in optometry is the Merit-based incentive payment system MIPS.

The MIPS program may impact your Medicare reimbursement in 2020 depending on how you perform in 2018. Most OD’s, who are in their first year of being a Medicare provider or see fewer than 200 Medicare patients in a calendar year or will charge less then $90,000 to Medicare in a 12-month period, will be excluded from performing the MIPS measures and will automatically receive 100% of Medicare reimbursement. This is both good and bad for the provider as fortunately they do not have to perform or report any measures but they are not eligible to receive any incentive payments in addition to the Medicare allowable.

Being new to the world of medical billing in optometry does not necessarily have to hold you back as long as you are willing to commit the time needed to learn correct and ethical coding procedures. Also, make sure you are credentialed correctly the first time for all carriers and ensure your claims are being processed by an experienced well-trained billing specialist.

If you want to start a medical optometry practice, or learn more about coding and billing in optometry, read this guide to learn how to get started.

About Eric Botts O.D.

Eric Botts O.D.
Eric K. Botts has a Doctorate of Optometry from Southern College of Optometry, is a Third Party Trustee for Illinois Optometric Association, the President of the Energeyes Association, the Founder & Doctor of InnovativEyes Clinic, and the Founder & CEO of OBC Insurance Billing and Credentialing Specialists. Dr. Botts is a very passionate and engaging speaker with decades of real-world experience. He has hosted well over 250 Continuing Education Courses to 1,000s of fellow ODs! Besides having distinguished credentials Dr. Botts is a family man who has 3 daughters with his wife Lori, and they reside in the Midwest town of Macomb, IL.

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