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Guide to Optometry Billing and Coding

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According to the US Center for Disease and Control (CDC), approximately 12 million people in the United States have some form of vision impairment. Another 93 million adults are at a high risk of severe vision loss. With such startling revelations, experts estimate the employment gap for Optometrists to increase faster than most regular occupations in the US. As the demand for optometric treatments rises, practicing optometrists must streamline their billing and coding process to ensure they follow proper procedures.  

To help you get started, we have put together a definitive guide about optometry billing and coding. 

Billing and Coding for Optometry 

Whether you are opening a practice or looking to create new vision plans, the following steps can help streamline your billing and coding process: 

Select Insurance Panels and Credentials 

Before you select the panels for your practice, it is vital to research your locality’s biggest employers. You should also determine the reimbursements on the different vision plans you want to participate in. Ideally, different carriers have diverse credentialing rules, and the key is to go for a provider with a large recipient base. If your practice is not as busy, you should choose a carrier like Medicare. 

Medicare has nearly 60 million recipients, which is likely to rise to 80 million by 2030, which means that their patients are well distributed and can be found anywhere.  Additionally, unlike some carriers that close their panels or limit the number of ODS that they accredit, Medicare accredits all doctors that apply. Other great options include commercial carriers such BCBS, CIGNA, and AETNA. They all have better-paying plans, but they can be more challenging to credential for.  

Set Exam Fee 

If you choose Medicare as a provider, you should also accept the assignment. Here, the provider, doctor, or supplier agrees to accept the Medicare-approved amount as complete payment for included services as required by the law. This requires you to sign an agreement to accept assignment for all Medicare-covered services. Accepting assignments lowers your patients’ out-of-pocket expenses, which can translate to more patients in the long run. When determining what to charge for exam fees, review the latest Medicare allowable for your state

Learn How to Submit Your Claims 

Once you have set your fees, master all the proper steps to submit your claims. Using the appropriate steps guarantees timely reimbursement from medical insurance carriers. The best way to submit claims is by leveraging the power of multiple tools that ensure a thorough inspection. You can submit your claims through an EHR, a clearinghouse, and a reliable medical biller. You should also train your staff on optometry coding procedures to ensure accurate claim submissions and consistent cash flow. 

Where tenable, consider outsourcing your billing to professional Optometric billing consultants. Apex EDI has developed an exceptional OneTouch Solution that offers you an easier, more convenient, and less expensive way to submit and process your insurance claims electronically so that you receive reimbursements faster. The OneTouch Solution can be sued for claim submission, claim scrubbing, and much more. 

Master Proper Optometry Billing and Coding Procedures 

Ideally, billing should be performed by well-trained billing specialists. However, coding should only be done by the doctor. If you are a healthcare professional using EHRs platforms to perform your duties, master proper and ethical coding procedures that guarantee all claims are coded correctly. There are thousands of diagnosis codes specific to each specialty.  

The following tools can help you learn billing and coding for optometry: 

How Medicare Works websites such as The Fee Schedule and the MIPS Incentive Program and Modifiers  

Familiarize yourself with Eye Exam CPT Codes 

Once you have mastered how to submit your claims successfully, it is time to acquaint yourself with optometry coding guidelines for medical and routine exams. This measure is an integral part of Optometry practice, and it is essential that you keep detailed records of the kind of exam you perform on each patient. Breakdown the CPT codes as follows: 

Optometry Coding Guidelines 

Ideally optometrists can use both the 92xxx evaluation and management codes and the 99xxx general ophthalmological service codes. The 99xxx codes are used depending on the health history, exam elements, and medical decision-making documentation. The 92xxx codes can be broken into:

CPT code 92004 descriptions:
 this code covers medical examination evaluation with initiation of a diagnostic treatment program which can be comprehensive, new patient, one or more visits. 

CPT code 92014 descriptions: medical evaluation and examination, with the initiation or extension of diagnostic and treatment program; comprehensive, established patient, one or more visits 

92002– Medical evaluation and examination with the initiation of the diagnostic treatment program; intermediate, new patient. 

92012- Medical evaluation and examination, with the initiation or extension of diagnostic and treatment program; intermediate, established patient. 

Optometry Procedure Codes 

Apart from the CPT codes for office visits, you should also familiarize yourself with the procedure codes. These codes include: 

The bilateral procedures 92250 Fundus Photos  

92083 Threshold Visual Fields 

Ideally, the bilateral procedures feature one fee that is charged whether you perform a procedure or not. On the other hand, unilateral procedures such as the 65222 Corneal Foreign Body Removal charges a fee for every eye when doing a procedure on both eyes. You should also note that new ICD-10-CM codes are announced every October and take full effect on January of the subsequent year. 

Tips to Improve your Billing Collections  

You can improve your collections with these optometry medical billing tips: 

Verify Approval 

One of the critical steps in optometric medical billing is ensuring the insurance payer has credentialed the provider. Track and submit provider approval applications as per the insurance plan requirements. You should also make it a routine to regularly follow up with the insurance payers to guarantee that the providers are enrolled in-network when enrollments are open. 

Maintain Accurate Coding E/M Records 

Ensure you are keeping accurate records for coding E/M services the patients received for each visit. In 2019, CMS laid down several l E/M documentation modifications to help doctors streamline patient record documentation. If you are starting a practice, go through the changes to understand the new reference, review, and verification steps. 

Avoid Rejections, Denials, and Fines 

Use modifiers correctly to avoid denials, rejections, and fines. Most offices bill a fundus photography (CPT® code 92250) and an OCT/GDX (CPT® codes 92134/92133) on one visit. Failure to code correctly will ultimately result in denial on both codes and the lowest possible reimbursements. Check out all the CPT® codes on American Medical Association®. In addition, you can leverage Apex EDI products and services to increase productivity, improve efficiency, and avoid rejections, denials, and costly fines. Apex EDI takes the headache out of all claim processing and guarantees an accelerated patient payment collection process. 

Stay Current with LCD, MAC, and Listserv Updates 

You can stay up to date with all coding updates by reviewing any changes that may come through. To guarantee that you are coding your eye care claim correctly, ensure you are up to date with the following: 

Local Coverage Determinations (LCD)  

Medicare Administrative Contractors (MAC) 

You should also sign up to receive payer listserv updates.  

Outsource Your Eye Care Billing to Experience a Positive ROI 

Keeping up with the ever-changing ophthalmology billing rules can be frustrating and time-consuming. If you have trouble with your optometry billing and coding, why not bring in the experts?  

At Apex EDI, we offer exceptional solutions designed to simplify the claims delivery process. We offer real-time eligibility verification, OneTouch® electronic claims processing, patient statement delivery, electronic remittance advice (ERA), and tools that accelerate the patient payment collection process. Are you ready to experience a positive return on investment? Schedule a demo of Apex EDI today.  



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