When you’re first getting started with your optometry practice, billing and coding can seem like a daunting topic, leading many to search for assistance and guidance. Unfortunately, this topic is not thoroughly covered in your schooling, or at least not regularly. This article will offer a brief explanation on the matter, but for more thorough guidance or mentorship on the subject, we highly suggest learning from other optometrists or joining an optometrist network group like PECAA.

Introduction to Optometry Billing and Coding

how to do billing and coding for optometry

An old medical billing adage states that “If it’s not documented, it’s not done”, and that still rings true today. Just like any of the other medical specialty fields, optometry has very specific documentation and reporting guidelines, procedures, and policies to follow. While very strict in terms of accuracy and timeliness, all practices are bound by these rules and insurance companies are sure to call them out if they don’t follow along.

In order to be fully reimbursed by any insurance agency, all claims must be highly detailed and free from errors. Insurance companies are no strangers to rules and regulations as they themselves are also held to high standards and expectations from patients and clinics alike. For the best relationships between the doctor, the patient, and the insurance agency, thorough, timely, and accurate documentation of all conversations and actions is key.

Starting Optometry Billing and Coding Services

To start the process, you must first decide which insurance panels are right for your practice and become credentialed, or recognized, by each. An insurance panel is a group of doctors that work with an insurance company to provide health services to enrolled clients. Each insurance company operates within its own panel, so doctors should work with multiple insurance panels to be more accessible to more patients.

Choosing the right insurance panels is an important decision that requires careful research of local providers and competitors. First, determine the largest employers in your target area and then figure out which insurance is predominantly used for each. The next step would be to review the reimbursements plans for each company and factor them into the vision plans you are considering providing. It’s important to note that insurance credentialing rules vary from state to state, so it’s best to speak with other optometrists working in the same area.

Common Mistakes in Billing and Coding for Optometry

Over the last 10 years, the optometry field has expanded its scope of practice, resulting in more extensive optometry billing practices and not enough accurate codes to bill with. Whether there is a code for a diagnosis yet or not, clients will continue to come in for emergencies and routine care. More often than not, some of the most costly mistakes made by doctor’s offices end up being the result of incorrect billing that is done innocently, without malice or bad intentions.

But insurance companies are not analyzing claims for intent, they are reviewing them for accuracy of the diagnosis and cohesion with the provided exams. When a situation arises where the code for a medical condition does not yet exist, the treating doctor can be put in a difficult place. The best way to combat optometric billing and coding mistakes like these is to stay current on all ICD-10 Codes and relevant, accepted procedures.

The following examples are some of the more common mistakes made by new and upcoming optometry clinics:

  • Submitting a claim to a routine insurance carrier: Routine insurance carriers process millions of claims resulting in much lower reimbursement. Over time these little sacrifices can become a huge financial burden for your practice. The best way to avoid less than acceptable reimbursements is to find the right insurance panel for your area and provide consistently accurate and detailed claims.
  • Using incorrect modifiers: Modifiers are two-digit codes linked to the CPT and used to describe the completed services more accurately. These codes can be great to justify nuanced procedures but when used incorrectly, they can result in a fully denied claim.
  • Submitting claims before proper credentialing: Submitting claims to insurance panels before being properly credentialed not only slows the process of reimbursements to your office but it slows the continued treatments plans for your patients as well. Doctors should verify their credentials before submitting claims to new insurance companies.

ICD-10 Codes for Optometry Billing

ICD-10 Codes, are alphanumeric codes used by doctors, health insurance companies, and public health agencies to represent symptoms and diagnoses. ICD-10 stands for International Statistical Classification of Diseases and Related Health Problems 10th Revision. If you are just starting your billing and coding journey and are unfamiliar with how the claims process works, it can be a little overwhelming trying to understand how ICD-10 codes fit into the mix.

Once a patient enters the office and fills out all required identification and insurance documentation, the exam is able to begin. After the exam, a detailed report of all symptoms, treatments, findings, and diagnoses is provided to the claims department or in-house coders. Based on the documentation gathered by all relevant care providers, including doctors, nurses, and medical technicians, the coder abstracts the billable information and provides relevant codes for each. After the coding process is complete, the billing agent will then input the codes into the appropriate forms, as each insurance company has their claims process, and then they will submit for reimbursement.

Getting to know the ICD-10 codes specific to the optometry industry is a very important step and one that will eventually save you a lot of time. As an optometrist, you’re likely to familiarize yourself with hundreds, or potentially thousands, of ICD-10 codes throughout your career. A helpful resource for memorizing the codes or learning more about each is ICD10data.com. This website allows you to search all diagnosis codes and can help you choose the most specific code for each scenario.

PECAA’s Exclusive Training: How to do Billing and Coding for Optometry

We hope this brief introduction to billing and coding for optometry has been helpful for you, but it’s important to note that the subject requires far more research than reading a blog post. Luckily, members of our network are provided access to PECAA’s billing and coding program which helps members learn to properly bill and code their practice’s medical and vision services with personalized consultations and exclusive, customized education opportunities.

PECAA’s billing and coding program is broken into three categories:

1. Optometric Billing: The optometric billing section of our training focuses on having consistent optical billing processes. This makes a big difference in receiving timely and accurate payments. This section will cover the following topics:

  • 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 (Centers for Medicare and Medicaid Services) rules and regulations to keep your billing practices compliant

2. Optometric Coding: The optometric coding section will keep you current on information related to CPT, ICD-10 and Quality Payment Initiatives. This section includes:

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

3. Revenue Cycle Management: The third section of PECAA’s billing and coding program offers recommendations to achieve complete and predictable claim cycle management by improving the following:

  • Insurance verification process
  • Patient revenue capture at the time of service
  • Optimizing the claim cycle workflow
  • Monitoring and managing accounts receivables
  • Managing aging patient balances

Help with Optometry Billing and Coding

If you’re new to billing and coding for optometry, our advice is to start slow, be thorough, and engage with other optometrists for cross-learning. If you’re interested in learning more about PECAA’s exclusive billing and coding program, feel free to contact us!

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