Running a successful optometry practice involves much more than just patient care. You must handle complex optometry coding and billing processes with a deep understanding of how medical insurance, insurance claims, prior authorization, reimbursement, and insurance billing works. In this article, our team at Weave, a comprehensive optometry billing and communication platform, shares the basics you need to know.
How To Do Billing and Coding for Optometry
Learning the ins and outs of medical billing services is daunting, even if you’re a billing specialist. Optometry medical billing requires precise adherence to various reporting guidelines, procedure code outlines, and policies. To receive the payout from insurance companies for your provided care, you must document accurately all examination and procedural services in a medical record within the required timeframe.
To understand medical billing properly, you’ll need to select insurance panels and credentials, set exam fees, learn how to submit a claim, and study the correct medical coding services. We cover each step in detail below.
Selecting Insurance Panels and Credentials
To begin, you should decide which insurance company providers you would like to offer at your practice. The panels you select will cover their insured party’s vision-related medical care (with restrictions). The different vision plans in which your practice participates will affect reimbursements, new patient growth, and established patient retention rates.
Every state has different popular insurance providers, so we can’t tell you which options will work best. We recommend studying which providers have the largest recipient pools so you can reach the most potential patients. For example, Medicaid services cover nearly 90 million beneficiaries across the United States, though they receive nearly 15 times the annual applicants in California as they do in Wyoming.
A few more of the nation’s largest medical insurance providers include the following:
- Blue Cross Blue Shield (over 62 million beneficiaries)
- Medicare (nearly 60 million recipients)
- Humana
- Anthem
- Cigna
- Aetna
- And more
When selecting insurance providers, you need to also consider the payment rates, patient populations, credential difficulties, and more. We recommend reviewing the top insurance providers in your area, then pick options that work best for your practice.
Setting Exam Fees
If you accept Medicare as an insurance provider, you can accept assignments that encourage Medicare beneficiaries to choose your practice because of the lower out-of-pocket costs. Understanding what these expenses should look like is challenging. You can review the Medicare allowables in your area to gain a better perspective on what you should charge for various exam fees.
For example, you’ll need to determine prices for the following services:
- Contact lens prescription renewals and fittings
- Eye care checkups
- Vision examination procedures
- Cataract surgeries
- Eye disease and condition treatments
- Dry eyes diagnoses
- Lasik surgeries
Setting exam fees can feel challenging. For a standard eye exam, you want to charge enough for your business and optometrist team to succeed, though not so much that the vision insurance leaves the payer with an enormous out-of-pocket fee. We recommend reviewing your insurance panel allowables and considering the local industry standards when setting your various fees.
Keep in mind that you should keep all fees the same for every patient. You may have some patients pay without insurance, with medical insurance, or with vision plans, resulting in various out-of-pocket fees. You can review past patient data to determine which type of patients your practice sees most often.
Knowing How To Submit Claims
After selecting your insurance providers and setting examination fees, you’ll need to learn how to properly submit a claim so you can promptly receive reimbursement from the payer. You can hire a professional medical biller to handle each claim or use electronic health records to make the process more efficient. Some practices also rely on clearinghouse services to check for errors, ensure that all the information aligns correctly, and receive trackable claim reports.
Once ready, we recommend the following steps:
- Carefully document all treatments: Optometry billing requires that you document all treatments, procedures, exams, or equipment that you provide. If you fail to make a note of even a simple vision exam, the insurance company won’t reimburse the funds. Accurate and detailed charting is critical in ophthalmology and optometry.
- Accurately submit claims on time: When submitting any claim, you must use the proper CPT code, ICD-10 code, E/M code, HCPCS “S” code, or ophthalmic visit code, depending on the care provided. We review these codes in more detail below.
- Wait for the payments: After submitting claims within the required period, you’ll wait for approval or denial. You will only get the payment after receiving approval.
Proper Optometry Billing and Coding Procedures
Billing specialists submit claims, though optometry doctors also need to understand how to report the proper codes associated with patient-related care. Many different types of office visit codes exist, ranging from general medical exams to treatments specific to optometry. The main types of codes that your team should learn for accurate charting include the following:
- CPT codes cover various types of procedures and comprehensive eye exams with CPT modifier codes to add more specificity
- ICD-10 codes cover all potential diagnoses in all specialties, including optometry
- E/M codes (evaluation and management) cover 10 different types of medical complaints and case management encounters
- HCPCS “S” codes cover non-medical related patient interactions
- Ophthalmic visit codes cover various medical evaluations and exams in ophthalmic settings
Depending on your treatment, one visit with a single patient may require multiple codes. For example, an exam, diagnosis, and treatment plan may each require a different code.
We recommend beginning with ICD-10 codes, which are healthcare industry standards. The American Medical Association and American Optometric Association provide in-depth resources on all the coding information you may need. We cover more specific types of codes below.
Guide to Optometry Codes
As an optometrist, you may not feel that coding is critical in patient-related care, though it can greatly impact the success of your business and the patient’s overall experience. Improper coding can result in adequate funds from the payer. Familiarizing yourself with the most common codes will make it easier to chart everything that happens during your daily patient visits.
Below, we cover the most common optometry coding guidelines as a starting point for you to continue learning from.
Optometry Coding Guidelines
The 16 essential CPT Codes break down into a few categories, including E/M codes, 2 HCPCS “S” codes, and ophthalmic visit codes. The most common 920xx visit codes you may need include the following:
- 92004: This code refers to a medical evaluation and exam, including the initiation of the diagnosed treatment program. You may use this for comprehensive, new patient, or multiple visit occasions.
- 92002: This code refers to the statement above, though with intermediate occasions.
- 92014: This code includes the same medical evaluation and exam criteria, though with the extension or initiation of the diagnostic treatment plan. You may use this for comprehensive, established, or multi-visit patients.
- 92012: This code refers to the same statement as above, though with intermediate or established patient occasions.
You can find a comprehensive list of all optometric procedure codes from the Executive Office of Health and Human Services. You can also find more information on all current, refined, and new ICD-10 codes at ICD10Data.com.
CPT code modifiers work like descriptors, allowing you to add more complex specificity to vague CPT codes. For example, RT and LT refer to the right or left eye. You can use modifiers to disclose the procedure’s necessity, attending doctors, past procedures, and procedure location.
Common Mistakes in Billing and Coding
With so many complex factors, it’s easy to make mistakes while billing and coding. Understanding the common errors can help you avoid these mistakes. A few typical mistakes include:
Submitting a claim to a routine insurance carrier: Medical and routine exam claims differ in a few ways, though people often confuse the two. Medical exams only refer to patients with a chief complaint that leads to a diagnosis or further examination. Routine exams happen on more regular bases and require little medical decision-making.
Using incorrect modifiers: Modifiers add specificity to claims, though they’re quite complex and often cause more confusion than clarity. Most modifiers use specific number ranges that refer to necessary information. A simple typo can change the claim’s meaning.
Submitting claims before credentialing: You must receive adequate credentials from your desired insurance panels before accepting their beneficiaries as patients and submitting claims. You should wait for the application approval before proceeding with any treatments.
Other common mistakes include over-coding exams above their billing value, under-coding below the service level, and incomplete coding processes.
Expand Your Practice’s Success With Weave
At Weave, we care about helping you find the best optometric billing solutions for your practice. Our team has a deep understanding of how optometry communication impacts patient care.
We believe optometry coding and billing shouldn’t be so challenging. We offer an end-to-end solution for transforming patient experiences and care, including easy payment collections, digital forms, and more. Request a live demo to see our product in action, or call us today at 833-572-2139 to speak with a Weave professional.
