The 3 Most Common Reasons for a Denied Optometry Claim
By: Kayla Groves, PECAA Billing & Coding Advisor

Whether you are a newly licensed optometrist or a seasoned veteran in the field, billing and coding mistakes are bound to happen. Simple errors can cause your claims to be denied resulting in little to no reimbursement for your time and services. Let’s go over three of the most commonly made errors when billing and coding and how to avoid them.

1) Improper or Incomplete Credentialing

Seeing and treating patients before you are fully credentialed happens a lot more often than one would think. Most insurance contracts will not back date claims prior to your application being fully completed, reviewed, and accepted. Seeing patients on plans that you do not have active contracts with, even if you are currently applying or plan to in the future, can be detrimental to your bottom line. Make sure you have a completely open line of communication between your biller and coder, your front desk, and whomever handles your credentialing. Keeping everyone updated on where you are in the process with each contract is crucial to having paid claims rather than denied ones.

2) Improper Coding: Routine Visits Versus Medical Care

One of the most commonly asked (and Googled!) optometry billing and coding questions is which set of codes to use: 92 codes or 99 codes. 92 codes are more commonly used for routine visits and typically billed to the patient’s vision insurance plan. 99 codes are more commonly used for medical treatment and are typically billed to the patient’s medical insurance plan. Of course, there are exceptions to every rule, so don’t take those “rules” too much to heart. It is important to remember that routine and medical exams have more similarities than differences, so be sure that your documentation covers the requirements for whichever code you are billing for.

The reason for the visit, or “chief complaint”, will typically decide whether you code the visit as medical or routine. However, you sometimes won’t know for sure until you start the exam, especially if the patient is coming in for the ever so common “blurry vision”. A lot of providers tend to make the mistake of treating all blurry vision chief complaints as an automatic refractive issue, when in fact there is often times an underlying medical issue that needs to be treated.

Also, be conscientious of the level of exam you are coding for. Many doctors tend to under code in an attempt to prevent an audit, however this can sometimes open you up for more liability than coding properly in the first place. While most medical optical exams will fall in a level two or three visit, with the proper documentation a level four is possible. Level five exams will almost always have you flagged for review, so if you submit one, be sure that your documentation is flawless.

3) Modifiers: The Make Or Break of Your Claim

Correctly applied modifiers can make a huge difference in the amount you are reimbursed on a claim, while incorrectly applied ones can cause the claim in its entirety to be denied. Familiarizing yourself with the most commonly applied modifiers and when to use them can drastically improve your reimbursement rate and lower your denials. Here is a brief description of a few of the most commonly used modifiers:

• RT/LT – signifies the left or right eye lid

• -25 – use this when you are performing two separate yet unrelated procedures
on the same day. For example, if you were performing an eye examination and then
found a foreign body in the eye that required a removal, the code for the foreign
body removal would require the -25 modifier.

• -55 – this code is used when co-managing post-operative care of a patient with a

o Pro tip: if you are performing post-operative care on a patient who had both eyes
surgically repaired, you must use a -79 modifier when coding the second eye to
ensure reimbursement is not denied as a duplicate procedure

No matter how long you have been in practice, billing and coding mistakes will happen. The important thing is to ensure you have all the necessary documentation to correct any denials and have those claims paid. If you follow these simple steps to avoid some of the most common errors, your claims paid rate should increase in no time!

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