Guide to Optometry Billing and Coding

Reading Time: 10 Minutes

How to Bill for Your Optometry Clinic

According to the American Foundation for the Blind, there is a significant increase of severe eye defects found in older people. Unfortunately, a large number of these people are in their 60s. Also, most experts forecast that the rate of vision loss will double alongside the aging US population.

Thus, within the next ten years, the employment of Optometrists will experience a sudden 18 percent increase. This rate is faster than most regular occupations in the US. This means the opportunities in this industry are vast and the potential for growth for both new and existing personnel is vast.

Here, we will provide a comprehensive guide about the optometry billing and coding sector. Unfortunately, this subject is hardly covered in optometry school, leaving students to often learn this difficult subject on the job.

Keep reading if you’re looking to gain comprehensive knowledge about Optometry billing and coding.

The Essential Codes in Optometry

Many optometrists and their staff find it difficult to code for an eye exam. Unluckily, this makes things harder than normal for them. On top of that, it sets many optometrists up to fall under the extreme scrutiny of an insurance auditor.

There are 16 ways of coding eye exams in optometry, making it important to understand the definitions and use of these essential codes.

In Optometry there are three standard code sets. They consist of:

  • The CPT codes for most procedures
  • The Health Care Procedural System for all procedures outside the CPT covering
  • The ICD-10 codes for diagnoses

The 16 essential codes are broken down into three sections; 10 evaluation and management (E/M) codes (992XX), 2 HCPCS “S” codes (S062X), and four ophthalmic visit codes (920XX).

Optometry is one of the few sub-fields to have its office visit codes. Eye coding examinations make use of 920XX codes. Thus, it’s simpler to meet the documentation necessities, especially the history components.

They’re the best to use for general examinations, even though they don’t cover all the possible situations. However, E/M codes come in handy for services that don’t fit the procedures for eye codes.

The Comprehensive and Intermediate ophthalmological services include integrated services. Also, Eye Code Visits are either intermediate or comprehensive. It applies to old and new patients who haven’t gotten any professional services within the past three years from a physician.

The most popular 920XX codes used are:

  • 92014- Medical evaluation and examination, with the initiation or extension of diagnostic and treatment program; comprehensive, established patient, one or more visits.
  • 92012- Medical evaluation and examination, with the initiation or extension of diagnostic and treatment program; intermediate, established patient.
  • 92004- Medical evaluation and examination with the initiation of the diagnostic treatment program; comprehensive, new patient, one or more visits.
  • 92002- Medical evaluation and examination with the initiation of the diagnostic treatment program; intermediate, new patient.

It’s important to note that refraction (CPT 92015) isn’t among the above-listed codes. It’s a separate and unique service that should be billed as a separate line item on a claim form with a different and separate charge.

It’s also pertinent for you to note the different visit types, now that you know the essential codes in Optometry.

The Comprehensive Exam

The comprehensive eye exam codes, which are 92004 and 92014 defines an overall assessment of the whole visual system. The CPT describes it as:

  • General medication observation
  • Gross Visual fields and sensorimotor examination
  • Patient’s History
  • External and ophthalmoscopic examinations
  • Examination with Mydriasis or Cycloplegia
  • Initiation of diagnostic and treatment programs
  • Biomicroscopy
  • Tonometry

A comprehensive eye examination involves a basic sensorimotor exam. It also involves gross visual fields, and the codes of a comprehensive exam need one or more visits.

The Intermediate Exam

The Intermediate eye exam codes are 92002 and 92012. It involves the assessment of an existing or new state complicated with new management or diagnostic problem. However, it isn’t related to primary diagnosis. The CPT describes it as:

  • General medicine observation
  • Use of Mydriasis for ophthalmoscopy
  • External ocular and adnexal examination
  • Patient’s History

For the intermediate exam, dilatation may be voluntary. Some physicians use the intermediate codes to lower the cost of the exam to a non-insured patient.

The E/M Codes

With patient encounters, you make more use of the E/M codes. The patient presents a continuation of medical case management or a medical complaint. However, it’s pertinent to keep in mind that using the codes for a general examination would put you at risk–especially under the scrutiny of an audit.

Using the Right Optometry CPT Code Modifiers

CPT code modifiers help to describe a service accurately since they’re often complex.

It will help you in achieving the following:

  • Defining whether the procedure is necessary.
  • Knowing how many doctors attend to the patient.
  • If there were many procedures in the past.
  • The location of the procedures and much other information important to a claim’s stand with the insurance financier.

However, if it’s applied in a wrong way, it could lead to a high percentage of denied medical claims. The most used modifier for ocular examination comprises of RT/LT for the left and right eye/lid. Also, the E1-E4 modifiers help in differentiating the left and right, as well as the superior and inferior lids.

The CPT modifiers are either alphanumeric or numeric. Thus, they are usually added to the back of a CPT code together with a hyphen. It’s wise to understand the various uses of each of the CPT code modifiers before applying them.

Common Optometric Billing and Coding Errors

There are three common billing and coding errors every optometrist should know and avoid. These common errors are:


Over-coding an examination occurs when you bill a level of service higher than the normal value. An example is when an E/M level 4 replaces the medical record that supports an E/M level 3.


It’s the most common error in optometry. It involves billing a problem-focused evaluation and management office; at a lower level than the examination, decision-making support, and the patient’s history.

Billable Procedures

This error is like the under-coding error, but it takes the under-coding a little step further. It happens when you don’t finish the coding process by billing the patient’s medical insurance for the examination.

When to Bill for a Vision or Regular Medical Insurance

Before you can find out which insurance is appropriate, you have to understand how refraction fits into the situation. Vision insurance is necessary for routine eye examinations. The vision insurance is also important for comprehensive codes that include refraction. In other words, even if refraction and an examination are carried out, the billing applies to just the examination code.

Medical insurance comes into play when there’s ongoing care for a medical condition, a medical sign, or medical symptom. But, it’s necessary to point out that medical insurance doesn’t cover some special cases where astigmatism, myopia, or hyperopia is the reason for the primary diagnosis or the examination.

Vision insurance runs once a year and medical insurance can run many times in a year. Thus, the best way to go about a case is to ensure that both insurances exist. In this way, you can use the medical insurance for the first visit, because the examination is for a medical reason.

When the patient is well, you can proceed to use the vision insurance as it covers refraction. This method helps you stay in line with insurance rules and organizes the patient’s insurance coverage. It also helps reduce the patient’s overall out-of-pocket expenses.

Steps to Take for Insurance Reimbursement

When it comes to insurance reimbursement, the first step is to ensure that you have proper documentation of your exam. If you fail to document any test conducted at all, it implies that you didn’t carry it out.

If you want to have a continuous cash flow for your practice, you have to take the step of choosing the right service for optometry billing and coding. The right service ensures that your insurance claims are well processed, and your practice is strong money-wise.

For you to pull this off with ease, it’s pertinent to submit all claims with speed and accuracy. It’s also necessary to work any existing accounts receivables alongside. The prompt and efficient submission of claims certifies that your 90 days and older AR is about 20% of the total AR amount.

It’s completely normal to have an AR older than 90 days as a result of some insurance carriers denying claims or taking longer to reimburse claims. The last step is necessary for a higher AR. All you need to do is wait for the patient’s payments after processing the claim and proceed to bill the patient for what is due. Also, if you want to avoid irrelevant patient billings, collect fees and co-pays the same day as the exam.

How to Choose the Right Insurance Panels

Choosing the right insurance panels requires thorough research. The research involves searching for the largest employers in your community. It also involves finding out what the reimbursements are on the different vision plan you choose.

There are cases where some carriers limit the number of OD’s that they credential or close their panels. You can avoid cases like this if you do your homework well. If you choose to go for commercial carriers like CIGNA and AETNA, you will get better-paying plans. Even so, these carriers are more difficult to certify.

While you’re doing your research, it’s necessary to bear in mind different rules apply to different carriers and state.

Submitting Claims to Clearinghouses

If you’re set to submit your claim, all you need to do is upload it to a reliable clearinghouse. Once you do this, the payer would receive it. Now, the question is what exactly happens when your claim gets to the clearinghouse?

Errors Are Checked

The clearinghouse checks the claims for any errors. Once the clearinghouse notices errors like clerical issues, revenue codes, they correct it online and forward the claim. If the errors aren’t any of those above (like an unknown payer), it could get difficult to fix. In this case, the provider’s office has to make corrections and resubmit.

The Right Payer Receives the Claims

Based on the payer’s identification number, the clearinghouse does payer matching to direct the claim to the payer. Once the payer gets the claims, the person processes the claim and decides the settlement according to the codes.

The Clearinghouse Generates Reports

A clearinghouse is responsible for keeping track of claims that go through its system. Records are kept by generating a report of all transactions that occurred. When a problem occurs, a report is also generated to indicate it.

An important tip here is to ensure a daily routine is done to check for any rejected claims and fix them immediately. This routine helps avoid timely filing denials.

Proper Credentialing for an Optometry Practice

There are some factors to consider before going through the credentialing process. Also, the process could get complicated. Thus, you should tread with caution. One of the factors is the type of practice you have. Whether it’s a large group or small group practice, it’s important you discover your risks and advantages. Once you do this, combine it with due diligence and scrupulous planning.

Proper credentialing helps to boost the RCM of your practice the moment it’s under a certain level.

The second factor to consider is a specialty. As an optometrist, you have to decide if you want to be credentialed by a sub-specialist, specialist, or general practitioner.

The third factor is the place of practice. The place you choose helps determine how you’re billed and coded in your optometrist practice. Your qualification and license is another factor to put into consideration. Before an optometrist gets credentialed, information on professional background and education is required. Other things needed are:

  • DEA license (if relevant)
  • Applicable certificates to dispense therapeutic agents
  • Current license to practice

Bottom Line

The fact that optometry medical billing and coding is new to you is no excuse for you to hold back. All that’s required is to make up your mind to dedicate the needed time to study the correct and ethical procedures.

However, you don’t have to go at it alone. At Apex EDI we have a team of experts here to help you with all of your optometry billing and coding needs, schedule a free live demo today.



Related Posts