Ophthalmology billing and coding can eat up a lot of precious time and resources. In fact, a Health Affairs survey found that doctors spend about three hours per week dealing with billing-related matters, and for each doctor, an additional 19 hours per week are spent by medical support staff.

Ophthalmology and optometry billing are especially complex and time consuming compared to other fields, which is why you must establish clear billing processes, stay on top of best practices, and invest in training and support as needed. If you can be more accurate, compliant, and efficient in your billing, you’ll see major improvements to the overall financial health and success of your ophthalmology practice.

Understanding the Ophthalmology Billing Process

First and foremost, let’s establish the importance of billing and coding in the field of ophthalmology. The overall financial health of your ophthalmology practice is directly related to efficient billing, accurate coding, and timely account reimbursement. In recent years, increasingly complex compliance issues and above-average patient default rates have made mastering ophthalmology billing even more challenging.

Although you may delegate your billing and coding duties to one of your staff members, it’s important to remember that the physician is ultimately responsible and will be held accountable for any mistakes or malpractice. Therefore, it’s crucial to set your team up for success with clear billing procedures and best practices, as well as access to regular training, resources, and support.

Ophthalmology billing involves many steps and processes, all of which should be mastered and regularly audited in order to improve your practice’s fiscal health and compliance. Put simply, the billing process can be broken down into these nine steps:

These first five steps should take place before the clinical service is provided:

1. Credentialing: As a first step, you must ensure that each insurance carrier has accurate records for your practice’s physicians and locations.

2. Patient Registration: Get accurate demographic and insurance details from new patients and maintain up-to-date records.

3. Patient Scheduling: When scheduling an appointment, make sure that patient information is accurate, check on deductibles, and calculate copay amounts.

4. Insurance Verification: Several days prior to a patient’s appointment, you should verify their insurance information, make sure it’s up-to-date, and follow up about any issues that arise.

5. Patient Check-In: At the time of check-in, be sure to collect any copays, deductibles, or refraction fees that apply.

After the clinical service is provided, complete the billing process with the following steps:

6. Charge Capture: Check on every service provided during the appointment and make sure it was recorded, captured, and identified as a charge.

7. Claims Submission: Prepare and submit claims for approval.

8. Accounts Receivable Management: It’s a good idea to plan ahead and try to determine when you expect payments to be received and their amount (based on insurance carriers). Post payments immediately upon receipt.

9. Follow Up: Review any unpaid or underpaid claims regularly. If you notice any errors, be sure to correct them and resubmit the claim.

With so many steps and people involved, there’s lots of room for error, but also lots of room for improvement! Read on for our top billing tips and tricks…


Ophthalmology Coding & Billing: Tips From the Experts

Now that we’ve established the importance of accurate billing and outlined the steps involved, we’ll share some expert tips and resources to help you audit and improve your billing and coding processes:

1. Understand who your payers are and master their documentation rules in order to submit clean claims.

This is one of the most important and complex aspects of ophthalmology billing. Documentation rules vary by payer, and commercial payers don’t always follow Medicare policies. For example, Medicare, Blue Cross, and United Healthcare all have different rules to play by, so don’t take one payer’s guidelines and apply them across the board. Some payer policies may be available online, but when in doubt, your staff should contact the provider representative for guidance.

2. Correctly choose between eye codes and E/M codes.

In the field of ophthalmology, unlike some other specialities, there are two different sets of codes to choose from, which can make things especially confusing and complex. In order to choose the correct code, be sure to refer to the specific payer rules and take into account the exam elements performed, the medical necessity requirements, and the reimbursement rates for the relevant codes.

3. Know your Medicare Local Coverage Determinations (LCDs).

LCDs can vary from state to state, so local research is essential. The American Academy of Ophthalmology provides the applicable local coverage determination policies for each U.S. state and some territories on their website – it’s a great resource to share with your billing team! LCDs are something you should look into regularly, because they are revised periodically. LCDs may include: indications, medical necessity, limitations and frequency edits, documentation requirements, approved CPT and ICD-10-CM codes, and more.

4. Master your modifiers to minimize denials.

This is the most important takeaway when it comes to coding reimbursements, because misuse of modifiers is the number one reason for denials. Keep in mind that billing for diagnostic tests is especially important and closely scrutinized by auditors.

5. Don’t forget to look into global periods.

Different payers (Medicare, Medicaid, and commercial) may have different global periods. It’s best practice to identify the global periods per payer for all your top surgical codes.

6. Monitor your comparative billing reports.

Comparative billing reports include a report of the types of procedures you use compared to peers in your state (and perhaps regional or national peers). These reports are provided by Medicare and commercial payers. It’s important to note that the reports compare all of ophthalmology, not specific sub-specialities, so if you have a specific area of expertise, some differences are to be expected. Overall though, these reports can be used to help you conduct internal audits and ensure you’re meeting certain standards and requirements.

7. Be careful with out-of-network (OON) billing.

At some point, you may feel the need to bill OON, without a payer contract. Although payers often pay OON claims at a higher rate, which can result in increased revenue, billing OON is a potentially risky move. Billing OON may result in increased denials, later payments, and in extreme cases, even violations of fraud and abuse laws.

8. Simplify your patient billing statements and make your billing processes user-friendly.

You don’t want to give your patients any more reasons to put off making their payments! So avoid using too much medical jargon and include clear and concise directions with your billing statements. An accounts receivable aging report can help you compare your billing and AR to others in the industry. According to Healio, “for most ophthalmology practices, balances less than 30 days old represent 40% to 60% of the total, balances between 31 and 60 days old are 15% to 25% of the total and amounts older than 120 days are 10% to 20% of the total”.

Ophthalmology Billing Codes: Resources & Support

As you can probably tell, ophthalmology billing and coding is complex and ever-changing, with plenty of room for error. Fortunately, if you feel you need a little extra support, you have several options, including outsourcing, training, and consulting.

Rather than audit and improve your in-house billing, some ophthalmology practices choose to outsource their billing instead, although this can be expensive. If you do choose to outsource your billing, look for a partner that can offer proven expertise, strong references, transparent pricing, and the latest technologies.

If you’re looking for high-quality training, the American Academy of Ophthalmology has a great library of training and resources related to ophthalmology billing and coding. Professional Eye Care Associates of America (PECAA) also offers free billing and coding workshops to its members.

If you’re doing your billing and coding in-house, you may want to invest in some billing consulting and advising in order to ensure your compliance and efficiency. PECAA’s billing and coding advisor can help your eye care practice with the following:

  • 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
  • Coding support
  • Accounts receivable management
  • Revenue cycle management
  • And much more!


Join PECAA & Master Ophthalmology Billing 

Need some ophthalmology billing support? PECAA’s Billing & Coding Program offers assistance to eye care professionals to help enhance claim submission, coding and revenue cycle processes to improve practice efficiency, profitability, and compliance.

In addition to this comprehensive program, PECAA members have access to free training, resources, consulting, and networking opportunities to help them establish and grow successful optometry and ophthalmology practices.

If you’re feeling stressed about your ophthalmology billing, know that you’re not alone; we’re here to help and support you! Contact us to learn more or join PECAA today.


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