Optometry Billing Guidelines

To keep an optometry practice running smoothly, you need excellent patient care and efficient revenue cycle management. While patient care is your area of expertise, we can ensure you get properly reimbursed for the services you provide. For financial stability, compliance with regulations, and timely payment from insurance companies and patients, you must adhere to the optometry billing guidelines.

In the dynamic field of optometry, the legal requirements for coding and billing are constantly being updated, and keeping up with them can be a challenge. Let us introduce you to the framework and guidelines for appropriate documentation, coding, and billing so you can avoid legal pitfalls and manage your revenue efficiently.

Documentation Requirements

Optometry billing involves submitting claims to insurance providers for the care and services delivered by eye doctors. Since healthcare providers need to carefully examine each claim, documentation is one of the cornerstones of optometry billing.

Detailed and accurate documentation is required to support the optometry claims and ensure a smooth-running reimbursement process.

The first thing you should do as a healthcare provider is document everything about the patient and their visit in detail. Documentation regarding the procedures, exams, treatment plans, and equipment you provide is of significant importance. In our experience, even small things like not having notes from a vision exam can result in a denied claim.

Furthermore, to ensure proper reimbursement and compliance with regulations, you must collect the following data:

• Patient’s personal information, demographics, and medical history
• Patient’s insurance details
• Clinical notes, including reason for visit, diagnosis, and examination details
• Documentation of tests provided
• Treatment and prescriptions
• Signed, dated, and detailed progress notes

Verification of Insurance Benefits

One of the best practices provided by the optometry billing guidelines is to verify the patient’s insurance benefits before scheduling an appointment and providing services. As a healthcare facility, the patient’s insurance verification process is crucial for minimizing the risk of denied claims because the insurance company doesn’t cover particular optometry treatments or services.

The verification of insurance benefits is typically done by an insurance verifier. In a nutshell, their job is to verify the patient’s information and check their insurance coverage. There are various items that the insurance verifier should verify, such as:

• Payable benefits
• Co-pay and co-insurance
• Deductibles
• The policy status of the patient, effective date, type of plan, and coverage details
• Plan exclusions
• Claims mailing address

The eligibility and benefits verification process is equally important for healthcare providers as it is for patients. From the provider side, insurance verification reduces claim denials, allows providers to make informed decisions about treatment plans, and maximizes claims reimbursements.

On the other hand, insurance verification is also beneficial for patients because it protects them from unplanned costs, informs them about their financial responsibilities upfront, and enhances their patient experience.

Coding Excellence

Coding inaccuracies are one of the top reasons for rejected claims by insurance carriers. More specifically, the most common denied claims are because of:

• Mis-matched procedure and ICD-10 codes
• Outdated billing codes
• Claims submission without proper billing modifiers

Optometry coding presents many challenges, including duplicate claims, medical necessity, incomplete or invalid modifier usage, and the difference between medical insurance and vision insurance.

Achieving coding excellence, or even better, outsourcing your entire optometry coding process, reduces the risk of having denied claims. Accurate coding requires understanding and selection of the appropriate CPT and ICD-10-CM codes. Also, keeping up with the latest annual updates is a must.

The optometric procedure codes can be divided into two categories:

• Surgical procedures
• Evaluation and management codes

Other optometry codes that are often used include:

• Visit codes such as 92004 and 92014 for general evaluation of the visual system
• E/M codes for patients who have medical complaints or recurring medical case
• S codes as a subset of the HCPCS codes

Claim Submission Processes

Once the treatments, services, procedures, and diagnoses are translated into universal optometry codes, a claim is created in the billing system. The claim must be submitted to the payor in a timely manner. Generally, the claims are submitted to the insurance carrier. However, there are also situations where they must be sent to the patient. 

One of the best practices for optometry service providers is utilizing electronic claim submissions. Integrating advanced technology and software can improve the claim submission process’s efficiency and accuracy. Compared to paper submission, electronic submission increases transparency and clarity while contributing to a faster billing and reimbursement process.

What’s more, digital billing systems offer various analytics and reporting tools that are extremely helpful for improving revenue cycle management. They can be integrated with Electronic Health Records, and some are even entirely customizable and scalable according to your practice’s needs and preferences.

Denial Management Strategies

According to KFF, 17% of in-network claims are denied, with insurer denial rates ranging between 2% and 49%. To avoid being included in these statistics, your healthcare facility should have proactive denial management strategies tailored to your optometry practice.

If you have an in-house coding and billing department, you must track your denial rates. The average rates in healthcare vary between 5% and 10%, making it the sweet spot for optometry practices. If your denial rates start to increase and go above the average, it is a sign that you should try to find the cause and make appropriate changes.

Besides denial analysis and tracking, effective denial management strategies are:

• Denial categorization
• Promptly appealing to denials
• Building a preventive mechanism for denials, such as including pre-verification and pre-authorization
• Keeping up with the latest denial trends in insurance carriers
• Doing regular audits and reviews of the coding and billing process
• Utilizing technology and software advancements such as denial management softwares, clearinghouses, and electronic health records

Outsourcing Solutions by CLICKVISION BPO

We understand that, as a healthcare provider, you have a lot on your agenda. To get one of the biggest burdens off of it, you can outsource your optometry billing. Our expert team can streamline your revenue cycle management and take over your medical billing and coding. 

By outsourcing your optometry billing tasks to CLICKVISION BPO, you will get:

• Improved accounts receivable balance
• Timely and accurate patient eligibility verification
• Maximized reimbursements and minimized denied claims
• Accurate and up-to-date coding and billing
• Minimized coding and billing errors
• Effective claims submission and denial management

With CLICKVISION BPO, you can get all of this and much more at a competitive rate. Outsourcing is more cost-effective than managing an in-house medical billing and coding department, and you get access to our experienced billers and coders.

Conclusion

For effective optometry billing, your practice must have a comprehensive understanding of the regulations and latest changes in the medical billing world. With our optometry billing guidelines, you are now familiar with the basics of the process and know that the entire process is not set in stone. It definitely requires continuous education.

If you want to optimize your optometry practice’s revenue and ensure compliance without breaking the bank or constantly training your employees, outsource the coding and billing to CLICKVISION BPO and let our experts do the administrative work for you. Schedule your free consultation now, and we can create a tailored strategy to streamline your billing process.