Optometry billing and coding

Running a successful optometry practice takes much more than just patient care. It takes a long time to understand the complex billing and coding processes an optometry practice requires. Among other issues, it is essential to understand how medical insurance, claims, reimbursements and billing work. 

Plus, it’s also crucial to understand the difference between medical plans and what copays may apply depending on the type of visit. In the long term, these will be some of the many key aspects that will help your patients feel more at ease, and getting them under control is also a good way to make you and your team’s job much easier.  

However, learning optometry billing and coding can seem a bit overwhelming, posing quite a challenge for many specialists. To help avoid this and speed up the process for you, you should always be up-to-date on everything that can affect how your optometry practice runs.  

In this article, our CECOP team will share basic concepts you’ll need to know to navigate these two processes.  

 Optometry billing and coding

How to handle optometry billing and coding  

If you run an optometry practice, you’ll know first hand that billing and coding can be a disheartening subject that drives many specialists to seek help and guidance.  

It is essential to understand all the ins and outs, so in this post we’re bringing you a short explanation of the topic.  

Introduction to optometry billing and coding

Just like any other medical profession, optometry also has highly specific guidelines, procedures and policies on documentation and reports. Not to mention that they are also very strict in terms of precision, as everything in this area is subject to rules.  

Insurance companies are no strangers to rules and regulations, as they are also subject to high standards and expectations of patients and practices. So, to ensure the best relationship between the doctor, patient and insurance company, it is key that all documents are complete and accurate. 

Don’t forget, in medical billing for optometry, to get paid for the services rendered from the insurance companies, you have to document all exams and procedures (by the deadline and accurately). 

Starting optometry billing and coding services 

To start the process and understand it fully, below we’ve laid out all the steps to follow. 

Select insurance panels and credentials for them 

You have to decide which insurance panels best suit your practice and get credentialed for each one. An insurance panel is a group of specialists that work with an insurance company to provide healthcare services to their clients. Each insurance company works with its own panel, so any optometrist will want to be part of several insurance panels so they can see as many patients as possible.  

The panels you choose will cover vision-related medical care for its policyholders (with some restrictions). Plus, the different vision plans your practice takes part in will affect reimbursement, taking on new patients and patient retention rates. 

In the US, insurance credentialing rules vary from state to state, so it’s always best to talk to other optometrists working in the same area. 

Set exam fees 

It may seem like a challenge, but setting your exam fees is key. To do so, we recommend you check the rules of your insurance panel and consider local industry standards in setting your various fees.  

Remember, all your rates must be the same for all patients. Some will pay out of pocket, while others will be covered by medical insurance; this means what each patient has to pay will depend on their individual circumstances. 

Learn how to submit your claims

Once you’ve set your rates, you have to learn how to submit your claims so you’ll get a timely, efficient reimbursement from the medical insurance carriers. To do so, you can hire a professional medical biller who will handle each claim or use an EHR clearinghouse. Having multiple tools on hand ensures the most thorough inspection possible! 

Know proper optometry billing and coding procedures

Billing specialists are in charge of the claims. However, the coding must always be done by the optometrist. So, doctors have to learn proper, ethical coding practices to ensure claims are coded correctly.  

There are many different codes for visits, ranging from a routine eye exam to specific optometry treatments. The main types of codes your team needs to learn are: 

  • CPT codes: these cover several types of procedures and medical eye exams, with modifier codes to make them more precise. 
  • ICD-10 codes: these cover every potential optometry diagnosis. 
  • E/M codes (evaluation and management): these apply to visits and services that involve evaluating and managing patient health. 
  • HCPCS “S” codes: these apply to patient encounters not related to the specialty. 

Depending on the treatment required, one visit can require several codes. 

Of all the codes mentioned above, we recommend optometrists start with the ICD-10 codes, as they are the healthcare industry standard. 

Getting familiar with the specific ICD-10 codes for the optometry industry is an important step that will save you a lot of time. As an optometrist, you’ll probably work with lots of ICD-10 codes over the course of your career. 

A helpful tool for memorizing the tools and learning more about each of them is ICD10data.com. This website lets you look up diagnosis codes and will help you choose the most specific code for each situation. 

Guide to optometry codes 

Optometrists have to master the basic codes they will use most every day, because basic knowledge of coding is key to providing good patient care and running a successful practice. Being familiar with the most common codes will make it easier for you to log everything that happens during visits with patients.  

Below is a description of the most common optometry coding guidelines: 

Optometry billing and coding guidelines 

Optometrists are the only doctors that can use both the 92xxx General Ophthalmological Service codes and the 99xxx Evaluation and Management codes. 

Like any other ICD or CPT code, the 99xxx codes are determined by the documentation of the health history, exam elements and medical decision-making of the optometry provider. So, it is important to first decide which procedure is required and what level exam you performed, in line with the codes. 

CPT codes 92004, 92014, 92002 y 92012

When you use 92xxx codes, it is important to remember that these don’t have as many guidelines for optometrists to follow and can be broken down into two levels: comprehensive CPT codes 92004 and 92014, and intermediate CPT codes 92002 and 92012.

  • 92004: This code refers to a medical examination and evaluation with initiation of a diagnostic treatment program.  
  • 92002: This code refers to the same as above, but with intermediate patients. 
  • 92014: This code includes the same medical examination and evaluation criteria with the extension or initiation of a diagnostic treatment plan. You can use this for comprehensive, established patients or one or more visits. 
  • 92012: This code refers to the same as above, but with intermediate or established patients. 

The CPT code modifiers act as descriptors, making imprecise CPT codes more specialized. For example, RT and LT refer to right eye and left eye, respectively. 

Most common billing and coding mistakes 

With so many complex factors in play, it’s easy to make billing and coding mistakes. The most common and frequent ones are: 

  • Submitting claims before being fully credentialed. 
  • Using modifiers incorrectly or not at all. 
  • Submitting a claim to a routine insurance company. 
  • Coding exams above the billing value. 
  • Coding below the service level. 
  • Incomplete coding. 

We hope this post has helped you, because we want to make optometry billing and coding a bit less challenging.