It takes time to become an expert in optometry billing and coding. Knowing the difference between routine and medical plans, what copays may be applicable to visits, or how deductibles will affect fees is crucial: it helps patients feel more at ease and makes 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! We’ve put together this massive optometry billing and coding cheat sheet for optometrists just starting out or for experienced ODs who want a thorough refresher!
In this complete guide, you’ll learn:
How to Do Billing and Coding for Optometry
If you’re opening a practice, there are steps you’ll need to take to start billing insurance for your patients. If your practice is already up and running, perhaps you’re looking to take a few new vision plans. Either way, these are the four main tips for streamlining your billing and coding process, and making sure you’re following proper procedures.
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 in. 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 nearly 60 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 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 expenses 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 ensures 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. Knowing how to do billing and coding for optometry is crucial for the flow of your practice, and it’s important that you and your staff are trained properly in optometry coding procedure—you can always outsource your billing to another professional (e.g., Optometric Billing Consultants).
The merit-based incentive payment system (MIPS) program may impact your Medicare reimbursement in 2020. Most ODs who see fewer than 200 Medicare patients in a calendar year in their first year of being a Medicare provider, or who 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 Optometry 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 optometry billing is from your fellow optometrists. Many coding experts work across the healthcare industry, so their advice may not be tailored to optometry billing requirements. Even the most important book on the matter, the ICD-10, is a healthcare industry standard.
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 ICD10data.com. Here you can look up any and all diagnosis codes you may need to code the eye exam, as it is critical that you accurately choose the most specific code available for every patient encounter.
Another convenient tool for learning billing and coding for optometry is the coding booklet I put together that can be found on Amazon or at claimdoctor.net. If you are willing to do your own research and want to learn more about how Medicare works then I suggest you visit the CMS.gov website where you can learn about the fee schedule, MIPS incentive program and modifiers as well as reviewing the 1997 Evaluation/Management Guidelines.
Eye Exam CPT Codes: Breaking Down the Comprehensive Exam
Once you’re credentialed, you’ve set your exam fees, and you know how to submit your claims, it’s time to familiarize yourself with optometry coding guidelines for medical and routine exams. These are the bread and butter of the practice, and it’s crucial to keep detailed records of when and which kind of exam you perform on each patient.
Optometry Coding Guidelines
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 medical billing codes are utilized by all health care professionals and are specific to medical-only exams with further 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.
CPT Codes 92004, 92014, 92002, and 92012
The 92xxx codes have fewer guidelines to follow and can be broken down into two levels: comprehensive CPT code 92004 and CPT code 92014, and intermediate CPT code 92002 and CPT code 92012.
- CPT code 92004 description: Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.
- CPT code 92014 description: Medical examination and evaluation with initiation or continuation of diagnostic treatment program; comprehensive, established patient, one or more visits.
The comprehensive exam often includes a retinal evaluation and typically is not performed more than once a year. The 92002/92012 eye exam CPT codes are more often used for anterior seg issues or follow-up visits.
Optometry Procedure Codes
In addition to the optometry CPT codes for office visits, 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.
Every October, new ICD-10-CM codes are announced to take full effect January 1 of the following year. The code changes for 2019 have been compiled by PECAA into a list of 2019 optometry coding guidelines—keep an eye out for the upcoming 2020 code changes.
Each of these optometry CPT codes describes specific procedures, and keeping detailed records will help you avoid the most common mistakes in optometry billing and coding!
The Three Most Common Mistakes in Optometry Billing and Coding
Optometrists who are practiced at billing and coding can still make mistakes. 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 impact billing and coding.
There are three extremely common mistakes in optometry billing and coding: mixing up routine vs. medical exams, using modifiers incorrectly, and submitting claims prior to being fully credentialed. Each of these can result in a denied claim—or even worse, an audit.
1. Routine vs. Medical
It is important to understand the difference between medical and routine exams to ensure you receive full reimbursement for your services. Distinguishing the difference between the two exams begins with knowing there are more similarities than differences.
Typically, the chief complaint and diagnosis drive the exam. Therefore, if the primary diagnosis is medical and addresses the chief complaint, then it 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 eye 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 eye 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 a routine/refractive exam requires little or no medical decision-making and a medical exam typically includes either low or moderate medical decision-making.
Medical decision-making may be broken down into 4 levels:
- 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 a patient who presents with three or more new problems. In that case, high complexity decision-making would be appropriate.
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 eye 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 or Submitting Claims Prior to Being Fully Credentialed
The third most commonly made error involves improper credentialing, 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. I strongly encourage you to seek proper legal advice from an attorney before beginning the credentialing process.
It is just as 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.
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.
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.
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.
How to Ensure Insurance Reimbursement After Submission
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 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 to wait 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.
Common Billing and Coding Questions
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.
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.
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, punctal occlusion 68761.
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 can be defined as demonstrating change from previous photos.
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.
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. This typically means the patient is presenting with a minimum of three new problems that I have not diagnosed or treated previously.
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.
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.
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.
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.
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.
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.
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 the same day. If you do two and two you must wait 10 days in between procedures, as there is a 10 day global period.
We put together a single-page billing cheat sheet for the busy optometrist. Download it now!
Optometry Coding Guidelines
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.
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.
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
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.
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.
Avoiding an Audit
What are the most common triggers of an audit?
- Over-use of 99205/99215
- Using the same code for every exam
- Ordering a supplementary test without medical necessity
- Billing for care not provided
- Significant variation of E/M code percentages from area doctors
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.
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.
Optometry Billing and Coding: Complex, Not Impossible
Committing the time to learn correct and ethical billing and coding procedures is crucial for any optometrist, whether you’re a new grad or an experienced practice owner. When optometry coding guidelines and vision insurance plans can change each year, it’s more important than ever for ODs and practice staff to stay on top of the details of billing and coding.
Did this guide hit all of the common questions and issues you’ve experienced in your practice? Let us know your thoughts and advice in the comments!