No matter what practice you are associated with, billing and coding for the claims can be daunting and become challenging within no time. Similar goes with optometry, learning billing and coding optometry can take time and give you a toll if the differences aren’t learned about applicable copays for visits, valid fees for appointments, and how deductibles will affect the whole billing process.
To accelerate the billing and coding process smoothly, you need to be informed of every particular detail that can affect your reimbursement process. The article will drive you through the process of optometry billing and coding that you need to consider.
How to perform billing and coding optometry?
If you are new to optometry practice, you need to consider these steps to begin the process of billing and insuring your patients. But if you’re already running a practice and landed on the page, then it is likely that you are looking for some updated tips for your optometry practice. Regardless of the reason, to streamline your billing process, you need to follow these four tips that can turn out to be game-changing for your practice if followed effectively.
Credentialing options and Insurance panels
Prior to selecting options for credentialing and panels for insurance, list down the competitive employers from your community and the insurance plans that you wish to continue for your reimbursement. Although, different states and jurisdictions have different credentialing and coding rules. Many of them have their own list of coding requirements that every provider needs to follow.
Plus, if you see a practice other than optometry having insurance and reimbursement plans that are working great for them, it is not necessary that it will work for you as well. It’s like one size doesn’t fit for every practice.
Besides, it’s hard to recommend the exact solution for your practice, as this decision will be the one that you need to take for your practice yourself. A federal insurance agency Medicare has over 60 million recipients and is specifically expected to cross 80 million recipients by 2030.
By mentioning the member count, it is sure that the patients for Medicare can be found everywhere, and connecting with insurance providers like Medicare can actually guarantee you a lot of patient visits and connecting with a rewarding firm will eventually increase your reimbursement rates.
Plus, Medicare approves all the providers who apply for them contrary to carriers who close their panels and plans for certain types of doctors.
Set treatment charges
It is also possible to accept assignments when you work with Medicare. Accepting assignments will add up as a positive sign to your practice. It will help encourage patients to choose your services as assignments lower patients’ out-of-pocket expenses as compared to non-Medicare payers.
However, Medicare rules vary across states, therefore, you need to see your state regulations before you move to Medicare and understand the out-of-pocket expenses look like. Once you understand the process and allowable fee rules, you will then be able to set your charges.
Submitting claims and reimbursements
Now that you know how to charge fees and how to connect with payers, learning to submit claims will be the next essential step that should be taken care of. It is important to receive regular and timely insurance reimbursement to smoothly run your practice. The process of effective and regular claim reimbursement includes an experienced biller who generates error-free claims using accurate CPT and ICD codes for billing claims regulated by American Medical Association (AMA) and Centers for Medicaid and Medicare Services (CMS) using Electronic Health Records (EHR) software, a clearinghouse (responsible to check and review error in a claim and the attached documents submitted for reimbursement. Using multiple checkpoints before submitting a claim will minimize the chances of claim rejection and a thorough inspection at more than one level will ensure accuracy.
In addition, a consistent cash flow at an optometric practice will directly depend on these inspection slabs and tools. Your practice relies on these core elements of business that need the management of a smooth revenue cycle that you cannot hand over to an untrusted staff member that you think might be inexperienced and know less about billing and claiming for reimbursement.
Billing and coding optometry is a key element in optometry practice. For the attainment of required targets, it is essential that staff members at your practice are completely trained and equipped with comprehensive knowledge of coding and billing. Also, whenever you find yourself lacking behind in billing and coding, you can always outsource your services to a competitive credentialing and consulting company, specializing in optometry billing and coding.
Another thing that affects your reimbursement and claiming process is the Merit-based incentive payment systems (PIMS) associated with Medicare. This works with the optometry practices that see less than 200 patients in the Medicare calendar years in their first annual year when they were connected to Medicare or even if they see 200 patients but do not generate over $90,000 in an annual turnover with Medicare, then they might get excluded from receiving payments from Medicare PIMS measures as incentives.
However, they will receive all their payments claimed at Medicare but not any incentives from Medicare or associated programs. There are always some good and some bad opportunities for providers under Medicare. To have incentivized allowances, optometry providers need to meet some specific requirements delivered by Medicare and Medicaid Services.
Knowing procedures for coding and billing procedures
Billing can be effectively done when the staff members and in-house billers are well-trained and experienced to handle claims of different codes. On the other hand, doctors are responsible to get educated about coding. They should know how to code and what codes are used for certain diseases and to ethically code procedures to code correctly. This education will be used to implement and understand the list of codes used in the optometry clinic.
Fortunately, there are resources that can be used to learn coding and billing and the complete process of revenue cycle management. On starting your billing practice, learn from your fellow providers. Oftentimes, experts in the medical claiming and billing process work across the medical industry to provide billing services as the procedure of billing is standard. However, the use of standardized ICD and CPT codes for optometry billing is standard.
ICD-10 codes are special in terms of coding and billing. They are specifically used in claims to specify hundreds and thousands of potential diseases through a large number of diagnostic codes.
CPT codes for EYE Exam – Things you need to consider
Now that you know how to charge fees and the process of billing and coding, you need to get familiarized with the routine and medical exams according to optometry guidelines. These exam guidelines are important as they provide detailed records of the treatment and exams rendered on each patient. Further, they help providers in using accurate codes against every treatment.
Billing and coding optometry guidelines
Optometrists are the only ones in the medical industry who have the luxury of being able to utilize 99xxx Evaluation and Management codes and 92xxx General Ophthalmological Service codes. In the medical industry, eye doctors are the only ones that can use both codes for routine and medical exams. These codes with 99xxx are only for medical professionals but they are used only for medical exams with an additional range of guidelines that a provider must follow.
Similar to any ICD or CPT codes, 99xxx codes will be determined by the medical history, medical decision by a provider, and the exam elements used by the optometric provider. Hence, it is important to decide prior that what procedure should be used and what level of medical examination should be performed at every level adhering to the guidelines.
Optometry CPT codes 92004, 92014, 92002, 92012
When using 92xxx codes, they have much fewer guidelines for the optometrists to follow and can be broken down into two levels further i.e., comprehensive CPT codes 92004 and 92014 and intermediate CPT codes 92002 and 92012.
- Description for CPT code 92004; CPT code 92004 is used with the initiation of the medical examination. It involves the evaluation of the diagnostic and planning of a comprehensive treatment program for new patients if they come for one or more visits.
- Description for CPT code 92104; CPT code 92004 is used with the initiation/continuation of the medical examination. It involves the evaluation of the diagnostic and planning of a comprehensive treatment program for new patients if they come for one or more visits.
- Description for CPT codes 92002/92012; When an eye exam is planned, it involves a comprehensive j retinal evaluation which happens to be performed once a year. However, these eye exam CPT codes 92002/92012 are more precisely used for follow-up visits.
Modifiers used in Optometry billing
- RT – right eye
- LT – left eye
- E1 – upper left eyelid
- E2 – lower left eyelid
- E3 – upper right eyelid
- E4 – lower right eyelid
- 24 – for post-operated E/M by the same optometrist
- 25 – Identifiable E/M for the same day treatment with the same doctor but for different treatment
- 51 – for multiple treatments performed on the same day
- 59 – Distinct procedure
- 79 – different services/procedures during the post-operative period by the same doctor.