optical billing codesOptometry billing and coding can be complicated and burdensome, but it is absolutely crucial that you get it right. Common billing and coding mistakes such as over-charging, under-billing or incorrect coding can trigger serious ramifications for your optometry practice, from financial audits to expensive fines, to charges of fraud and other criminal consequences. Considering these high stakes, investing time and resources toward mastering the art of optometry billing and coding will provide you with priceless peace of mind and security in the long run.

In this article, we will introduce you to the basics of optical billing and coding, tips for success, and common mistakes to be aware of. Lastly, we will provide you with plenty of resources in case your practice requires more thorough training or individualized support.

An Introduction to Optical Billing Codes

Optical billing codes are a complex system of code sets that allow for the accurate (if used correctly) transfer of specific information between the provider and the payer. Optical billing and coding employ multiple code sets established by different entities, each with specific purposes in the billing process. The primary optical billing codes used in the field of optometry are: the International Classification of Diseases, Tenth Revision, Clinical Modification code set (ICD-10-CM); the Current Procedural Terminology (CPT) code set, and; the Health Care Common Procedural Coding System (HCPCS) code set. Generally speaking, optometry practices use the ICD codes for diagnoses, the CPT codes for procedures, and the HCPCS codes for remaining procedures and products not covered in CPT. Codes must be adhered to carefully and applied according to both their stated definition and the carrier’s specific policies.

Keep in mind, this overview of optical billing codes just skims the surface of all there is to know — we highly recommend that you invest in thorough and specific training on each code set and their use. 

Tips on How to Do Billing and Coding for Optometry

As mentioned above, optical billing and coding is highly complex and cannot be mastered without more thorough training. However, to give you a sense of what the billing and coding process entails, here is a basic, step-by-step guide of what you need to do to get started:

  1. First, select insurance panels for your practice and credentials for them. Keep in mind that different states and carriers have very different credentialing rules, so do your research carefully. A general consensus is that Medicare is a must-have provider, though you should carefully consider which providers are best suited to your patient demographic. Medicaid is quite popular as well.
  2. Second, set your practice’s exam fees. It’s important to note that exam fees must align with regulations and limits in your state, so again, make sure to research this carefully.
  3. Next, make sure your team learns how to accurately submit your claims. This is essential in order to ensure timely and efficient reimbursement from your medical insurance carriers. If you doubt the skills or knowledge of your team, seek training and resources to get them up to speed.
  4. Finally, ensure you fully understand billing and coding procedures and seek support if needed. Billing is usually handled by administrative staff, while coding should be handled by the doctor. Again, ensure your team is well-trained and supported in this area.

For more information on optical billing and coding processes, check out our other blog post: How to Do Billing and Coding for Optometry. You can also visit our blog for frequently-asked optical billing and coding questions and answers.

Common Mistakes in Optical Billing and Coding

With so many code sets and carrier policies, billing and coding mistakes are quite easy to make. In general, it’s a good idea to familiarize yourself and your team with the most common billing and coding mistakes so that you can put plans and procedures in place to help avoid them. Below are a few optical billing and coding mistakes that are easy to make, but can lead to serious problems:

  1. Overall, the most serious mistake you can make is to over-charge on billing, which can lead to charges of fraud and other criminal consequences. Therefore, you should pay extra close attention to these types of errors.
  2. Inaccurate determination of routine vs. medical exams. For example, submitting a medical exam to a routine insurance carrier. This can result in incomplete reimbursement for your optical services, and can become a financial burden for your practice in time.
  3. Incorrect use of modifiers. Modifiers are used to describe optical services more accurately, but can result in denied claims if used incorrectly.
  4. Improper credentialing or submitting claims before they are fully credentialed for an insurance panel. This mistake can also result in denied claims.
  5. Using only eye codes (E&M codes). Make sure your team understands eye code criteria and reimbursement differences and is careful around when to use these codes.
  6. No-charge patient appointments.

To avoid mistakes like these, make sure you use guidance tools, educate and train your staff, have review systems in place to double-check the use of optical billing codes, track your errors and make plans to address them as a team. When in doubt, you should seek billing and coding advice from a professional optometry consultant. They can help you improve your systems and maximize your efficiency.

The Importance of Staying Up-to-Date on Billing Codes 

Medical billing code sets are frequently revised, which can cause administrative headaches for your optometry practice. For example, the eleventh revision of the ICD code set was put forth in May 2019 and will come into effect on January 1, 2022. It’s crucial that your optometry practice stays on top of revisions like these. We recommend providing your administrative team with regular billing and coding refresher courses and further support as needed. When optical billing code sets are updated, it can lead to a sharp learning curve and increased stress levels on your team, so it is important that your practice make sure that staff feel supported, fully informed, and prepared to implement changes accurately.

Optical Billing and Coding Support 

If all of this optical billing and coding information is starting to get overwhelming or you are stressed about making mistakes, do not worry! There are plenty of ways to get professional billing and coding support for your optometry practice.

First of all, we cannot stress enough the importance of investing in comprehensive and regular training for your team. One option is to regularly participate in optical billing and coding webinars. Our PECAA Billing & Coding Webinars are designed for individuals (opticians or optometry staff) looking to improve their billing skills and discover best practice solutions that can be easily implemented at their practice. The webinars cover a wide range of billing and coding topics specific to the field of optometry, including the following:

  • Life Cycle of a Claim
  • Billing Metrics
  • Action Plans
  • Insurance Verification
  • Claim Submissions and Coding Scenarios
  • Claim Denial Management
  • Application of Learning/Active Workshop
  • Vision Plans
  • Payments

Second, if you require more personalized optical billing and coding support, you can work with an optical Billing & Coding Advisor to discuss your current billing procedures and identify where opportunities lie in order to improve your practice’s efficiency, profitability, and compliance. Advisors can help your practice with financial reviews to help you spot and avoid mistakes. PECAA Billing & Coding Advisors can help your eye care with the following types of billing support:

  • Understanding individual payer policies for successful claim submission
  • Advising on efficient and effective billing processes
  • Understanding the explanation of payment from insurance payers
  • Effective claims resolution and denial management
  • Remaining up to date on CMS rules and regulations to keep your billing practices compliant

Furthermore, PECAA Billing & Coding Consultants will keep you current on information related to CPT, ICD-10 and Quality Payment Initiatives, through:

  • Optical coding support
  • Proper modifier usage
  • Documentation for compliance
  • ICD-10-CM support
  • Understanding Quality Reporting requirements

In addition to the above-listed services, becoming a member of a professional optometry group can provide your practice with access to additional forms of billing and coding support, such as revenue cycle management, peer-to-peer support, and access to staff training and professional resources. If you are ready to take advantage of comprehensive optical billing and coding support, and many more member benefits, join PECAA today.


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