Optometry includes curing vision-related problems, fitting lenses, diagnosing and treating certain ailments of the eye, sight testing, and correction by the initiation of diagnosis, treatment, and the supervision of vision changes. Having its own set of issues with billing and reimbursement, Optometry must focus on receiving the entire payment for the treatment provided.
Rules for enhancing Optometry billing:
1. Codes:
Enter the appropriate CPT/HCPCS/ICD-10 codes corresponding to the service performed. Also, include the necessary modifiers (e.g. 26, TC). Code to the utmost level of specificity as per the condition and not symptoms, and use the CMS-1500 form. List CPT codes in decreasing ‘Relative Value Units’ value (small procedures-low RVU, large procedures-high RVU).
Do not submit a 92000 eye exam procedure code along with a refractive diagnosis code as many insurance providers do not pay for refractive care.
Also, do not submit the 92000 eye exam procedure code which includes a refraction to a medical carrier. This is termed fraud as it is considered a bundling option.
However, not every test is barred from inclusion in an eye exam; one can bill for certain procedures such as laser interferometry, corneal examination, keratometry, slit lamp, tear film adequacy, etc.
2. Test definition:
Know the definition of the test ordered; i.e. if it is a “unilateral” or “bilateral” test, or if it is “unilateral or bilateral”? This configuration affects billing units and total charges. Create a carrier-specific manual in your office. Market to older, sicker patients, and identify the new/established ones.
3. CCI:
Knowledge of ‘Correct Coding Awareness’ prevents performing a specific combination of tests on the same day of service. Also, use Mod-59 to break an edit (National Correct Coding Initiative) for two procedures that should be independently identifiable. Small surgical procedures should be adequately documented (individually identifiable if reported with E&M with modifier 25).
4. ABN:
An ‘Advance Beneficiary Notice’ is necessary if the patient is to be billed for a non-covered service -pachymetry, or fundus photography (these services are not mandatory and the onus of the payment is on the patient if Medicare does not pay). Attach modifier GA to the code.
5. Rule-Out:
Optometry Billing documents “rule-outs” when detailing only distorted vision as the chief medical diagnosis; e.g. bacterial infection, cataract, optic nerve problem, corneal abrasion, glaucoma, tumor.
6. Compensation opportunity:
Optometrists perform the ‘Vision Therapy Services’ as a cash-only facility (CMS-1500 Box 19: Visual efficiency evaluation – 92060 (sensorimotor exam)).
An optometrist makes optimum use of advanced instrumentation for high-tech diagnosing. Consequently, billing has to be accurate for clean and swift reimbursements.
FAQs
Ensure you use the correct CPT, HCPCS, and ICD-10 codes with appropriate modifiers. Bill to the highest level of specificity for the condition treated, not just the symptoms.
Avoid submitting a 92000 eye exam code with a refractive diagnosis, as most insurers don’t cover refractive care. Submitting it to a medical carrier may be considered fraud due to bundling.
Understanding whether a test is unilateral, bilateral, or both is essential for accurate billing, as it affects the billing units and charges.
An ABN is required when billing a patient for non-covered services like pachymetry or fundus photography. Attach modifier GA to the code to ensure compliance.
CCI prevents billing incompatible tests on the same day. Use modifier 59 to separate two procedures when they need to be billed independently.
Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.
