Optometry Telemedicine Billing

Maximize Your Telemedicine Reimbursement

By: Teri Thurston, Billing & Coding Advisor, PECAA

Telemedicine gained tremendous traction during the recent practice shutdowns, in which only emergency eyecare was permitted to be provided in-person. Now, many patients, who had never experienced this new way of visiting the doctor, may be open to continuing to do so. Some may even expect the continuation of remote access to their eye doctor.

The most common misconception about telemedicine is that it doesn’t have a lasting place in the OD practice, and is not profitable enough to implement. Through the current health crisis, we’ve seen physicians and patients find benefit in accessing care through telemedicine services. Long-term, telemedicine has the potential in optometry to offer an additional revenue stream by expanding options for care delivery.

These days who hasn’t had a telemedicine visit! Patients are experiencing telemedicine visits with various specialties in all types of clinical settings and becoming familiar with the process. The Public Health Emergency (PHE) has opened up an opportunity for optometrists to try telemedicine services with relaxed restrictions, taking some of the pressure off providers.

Implementing telemedicine services during this time has allowed physicians to really see what works and what doesn’t, and how patients respond to virtual visits. Not only have some barriers of delivering care been lifted, but we have also seen an increase in reimbursements for telemedicine services.

What You Need to Know About Reimbursement

Telemedicine rules and regulations vary by state and by individual contracted insurance payer. Making sure physicians meet both requirements will be a key step in implementing telemedicine. The state rules depend on where the patient is being seen, rather than which physician is providing care. During the Public Health Emergency 1135 Waiver, however, this state-to-state restriction has been temporarily lifted to allow greater access to care.

Each telemedicine and telehealth CPT codes is based on how care is delivered, either by:

  • Real-time audio video communications allowing for face-to-face interactions


  • Through technologies that collect and store images or data to transmit and interpret later, or simply audio communications

Utilizing a HIPAA compliant platform, like EyeCareLive (a PECAA Vendor Partner), will be necessary in implementing telemedicine services, especially once the PHE 1135 Waiver is no longer in place.

It will be important for physicians and billers to understand the coding guidelines for each of the Telemedicine Evaluation and Management CPT codes. Determining the billing requirements for each contacted insurance plan, and verifying the patient’s coverage and benefits, will be an important factor to successful reimbursement outcomes.

Not All Payers Have Relaxed Requirements for Reimbursement

The majority of insurance plans have followed CMS recommendations following 1135 Waiver expansion. However, not all insurance plans are following CMS/Medicare billing guidelines or reimbursing on the same telemedicine and virtual care codes. The billing requirements for telemedicine E/M services can vary by individual insurance plan. Most payers have published on their web sites these billing requirements. By reviewing payer’s medical policies or COVID-19 webpages, you’ll generally find this information.

For example, Medicare does not reimburses for Online Digital Evaluation and Management services (99421 -99423), but you may find your local Blue Cross Blue Shield does. If you are receiving a denial for non-covered services, double-check the payer’s telemedicine/telehealth medical policy or their COVID-19 resources for a list of codes that are covered. Other denials may be received around invalid place of services codes, or improper use of modifiers due to changes made by CMS from March until now.

Going back and reviewing these changes may be beneficial if you are receiving a number of denials. Making the necessary corrections, and resubmitting the claims following the payer’s preferences for claim correction, should get denials resolved.

Resources to Help You Maximize Your Reimbursement

The public health emergency of the pandemic has shone a spotlight on virtual services, highlighting what is working and what is not, and CMS is paying attention to physician input. Over the last few months we’ve seen an increase in reimbursements in telemedicine and an expedited need for virtual services.

As optometry moves forward with reviewing opportunities for practice growth, telemedicine may prove beneficial. Even if you determine its not a good fit today, it may be worth revisiting in the future.

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