Optometry Billing and Coding Guide

Optometry Billing and Coding Guide

When you are getting started, optometry billing and coding is challenging. It takes time to become an expert, but starting out, just knowing the difference between routine and medical plans, what copays may be applicable to visits, or how deductibles will affect fees can help patients feel more at ease and make you and your team’s job much easier.

Unfortunately not much (if any) of this information is covered during your years of optometry school, so it’s up to you to teach yourself as soon as you graduate!

For this reason, we put together an optometry billing and coding guide for starting out.

Here are some tips for getting you started on the right path for billing in your new medical optometric practice:

1. Select Insurance Panels and Credential for Them

Prior to selecting the panels for your practice, do some research to find out who the largest employers in your community are as well as the reimbursements on the different vision plans you may choose to participate with. Unfortunately, different states (and different carriers) have completely different credentialing rules, so there’s never a one-size-fits-all solution.

Though we can’t recommend the perfect solution for your practice, we do have some safe bets. Medicare has over 50 million recipients today (and is likely to increase to 80 million by 2030). By volume alone that means that these patients can be found everywhere, making Medicare almost a must-have provider. Beyond that, Medicare also credentials all doctors that apply whereas some carriers will close their panels or limit the number of ODs that they credential. Medicaid can be a good option as well if your practice is not as busy.

Medicaid beneficiaries are one of the fastest growing insured populations in the country, but it’s important to keep in mind that Medicaid has lower reimbursement rates than Medicare in all states and can be significantly lower in some. Beyond the state sponsored carriers, commercial carriers like BCBS, CIGNA and AETNA are typically better-paying plans, but as we mentioned, can be more difficult to credential for. Take the time to review your options carrier by carrier to best understand which options best fit your patient population.

2. Set Exam Fees

In taking on Medicare as a provider, you can also accept assignment. Accepting assignment will encourage Medicare patients to see you because their out-of-pocket expense will be lower. But what will that expense look like? To get a good sense of what to charge for exam fees, review Medicare allowables for your state*.

3. Learn how to submit your claims

Once you’ve set your fees, learning how to submit your claims is essential in receiving timely and efficient reimbursement from medical insurance carriers. The most efficient way to submit claims is to use an EHR, a clearinghouse, and an experienced medical biller. Having multiple tools on hand ensure the most thorough inspection possible!

Consistent cash flow in an optometric practice is dependent on these staff members and tools. Accurate claim submissions are core to the business and should never be entrusted to an untrained staff member.

*Merit-based incentive payment system MIPS.

The MIPS program may impact your Medicare reimbursement in 2020. Most OD’s, who are in their first year of being a Medicare provider, see fewer than 200 Medicare patients in a calendar year, or will charge less than $90,000 to Medicare in a 12-month period, will be excluded from performing the MIPS measures. They will also 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.

4. Know proper billing and coding procedures

Billing is best performed by staff or outsourced to well-trained billing specialists. On the other hand, coding should always be performed by the doctor. It is the doctor’s responsibility to become educated on proper and ethical coding procedures to ensure all claims are coded correctly. That education starts with understanding which office visit codes to use.

Thankfully, we have great resources available that can be helpful in learning all about the coding process. Ultimately, the best place to learn about optometric billing is from your fellow ODs. Many coding experts work across the healthcare industry, so their advice may not be tailored to your specific needs. Even the most important book on the matter, the ICD-10, is a healthcare industry standard. In order to minimize your learning curve, check out the diagnosis codes on ICD10data.com! You’ll be able to search diagnosis codes that you’ll need for any exam. This way you can ensure quick and accurate code selection for each patient.

Another convenient tool for learning coding and billing in optometry is the Medical ICD-10 Coding and Documentation Guidelines: For Optometry by Dr. Eric Botts which can be found at claimdoctor.net.

If you want to learn more about how Medicare works then you can also visit the CMS.gov website where you can learn about things like the fee schedule, MIPS incentive program and modifiers, and review the 1997 Evaluation/Management Guidelines.

Optometry Billing and Coding

We have compiled some information here from billing and coding expert, Dr. Eric Botts, for getting started with some medical coding tips for ODs.

Optometrists have the luxury of being able to utilize both the 92xxx General Ophthalmological Service codes and the 99xxx Evaluation and Management codes. Only eye doctors can use the 92xxx codes and they can be used for both medical and routine exams. The 99xxx codes are utilized by all health care professionals and are specific for medical only exams with more specific guidelines you must follow.

99xxx codes are determined by the documentation of the health history, exam elements, and medical decision-making. Therefore, you must first establish what level of each you performed during the exam. The health history has four different levels depending on how much detail was documented on the Chief Complaint, HPI History of Present Illness, Review of Systems and Past, Family and Social History.

The 92xxx codes have fewer guidelines to follow and can be broken down into two levels comprehensive 92004/92014 and intermediate 92002/92012. The comprehensive exam often includes a retinal evaluation and typically is not performed more than once year. The 92002/92012 are more often used for anterior seg issues or follow up visits.

In addition to office visit codes, there are also procedure codes you must familiarize yourself with such as bilateral procedures 92250 Fundus Photos and 92083 Threshold Visual Fields. Bilateral procedures have one fee associated with them whether you perform the procedure on one or both eyes. Unilateral procedures like 65222 Corneal Foreign Body Removal allow a fee to be charged for each eye when performing the procedure on two eyes.

The Three Most Common Mistakes in Optometry Billing and Coding

1. Routine vs. Medical

While learning more about coding and billing and how they impact your practice, it’s also important to understand how you conduct your exams and how your duties as a doctor tie to billing and coding.

Typically, the chief complaint and diagnosis drive the exam, therefore if the primary diagnosis is medical and addresses the chief complaint then it is will most likely be billed as a medical exam. That said, don’t assume that every patient complaining of blurry vision has 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.

The medical decision-making may be broken down into 4 levels:

  • Straight-forward
  • Low complexity
  • Moderate complexity
  • High complexity

I prefer to simplify the decision-making process by focusing on two levels, the low complexity of follow-up visits and moderate complexity for the exam involving a new problem presentation. In this manner, it is quick and easy to establish the level of decision-making but keep in mind that occasionally you may see the patient who presents with 3 or more new problems and in that case, a high complexity decision-making would be appropriate.

If you do not employ an experienced medical billing specialist then contact Kenny Meyer at Kmeyer@claimdoctor.net and he can explain how OBC’s billing service can assist you in submitting claims for all your services resulting in full reimbursement.

2. Using modifiers incorrectly, resulting in denied claims

Modifiers are the best way to most accurately describe a service, but when used incorrectly they can lead to denied medical claims. Frequently used 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 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.

3. Improper credentialing and/or submitting claims prior to being fully credentialed

It is essential 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 establish a starting date prior to seeing Medicare patients. The starting date is typically the date they begin processing your application.

  • Properly identify patients and provide appropriate privacy measures for your patients.
      1. In order to share your clinical information with an insurance carrier, you must have either the patient or the under-aged patient’s guardian sign a Signature on File form. If you don’t submit a claim with the necessary codes for reimbursement and you can’t share that information without the patient’s permission you won’t be reimbursed by the carrier.
      2. Insurance carriers also allow a higher fee for new patients versus established patients so you must determine for every patient whether they are new or established. Medicare along with many other carriers define a new patient as one who has not been seen by you or a partner in the past 36 months and any patient seen within the last 36 months is considered an established patient. Most carriers have timely filing deadlines that you must follow for full reimbursement.
      3. Medicare allows you to submit a claim within one year of the date of service to receive full reimbursement, however, if you submit a Medicare claim after 12 months then it will be denied and you may only collect from the patient the 20% of the exam fee that Medicare does not cover. Other carriers may have timely filing deadlines as short as 60 days from the date of service so be sure to determine the deadline and submit your claims accordingly.

Reimbursement after submission:

Proper documentation of your exam is the first step to reimbursement. If the exam is not documented, then the exam did not happen. Document every everything. Ensuring that exams are document properly and that you and your staff are properly trained on coding and billing will ensure every exam is submitted and submitted properly.

Operating your own practice can be challenging, and with information about coding and billing scattered across insurance carrier pages, books, and traveling by word-of-mouth in the community, it can be even more challenging to nail down the right answers. Whether you already have a patient base and need to brush up, or you’re ready to build your practice, get started on more research by checking out some of our other articles and resources on optometry coding and billing.

About Dyllan Thweatt

Dyllan Thweatt
Dyllan is a UC San Diego graduate and the Associate Editor for NewGradOptometry and CovalentCareers. In his time out of the office he is also a full-time Dungeon Master, pet dad, and an avid tea drinker.

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