10 Optometry Medical Billing Tips to Improve Collections





An optometry practice shares the same end-goal as other small businesses—you want to thrive. A thriving business is one that focuses on growing revenue while providing great experiences for their customers. In your case, your customers are patients. Improving collections is an essential strategy for revenue growth. A healthy bottom line translates to a healthier financial trajectory for your eye care business. Follow these optometry medical billing tips to help your business thrive.




Improve Collections with These Optometry Medical Billing Tips


1. Verify the Insurance Payer Has Approved the Provider One of the first steps in optometric medical billing is making sure the provider has been approved (credentialed) by the insurance payer. Remember to submit and track provider credentialing applications based on insurance plan requirements. Take it one step further and follow-up with insurance payers regularly to make sure the providers are enrolled in-network when enrollment is open. 2. Keep Accurate Records for Coding E/M Patient Visits Always keep accurate records that document the specific Evaluation and Management (E/M) service (a category of CPT® codes used for billing) the patient received for the treatment —clearly reference, review, and verify. Starting in 2019, CMS announced several E/M documentation changes to help doctors streamline patient record documentation. Doctors no longer have to re-enter or re-document the patient's chief complaint and any history that ancillary staff or the beneficiary already entered in the medical record for E/M office/outpatient visits (both new and established patients). The doctor only has to add a note in the patient’s health record that the doctor reviewed and verified the information. 3. Use Modifiers Correctly to Avoid Rejections, Denials, and Fines Many offices bill an OCT/GDX (CPT® codes 92133/92134) and fundus photography (CPT® code 92250) on the same visit. If you do not code this correctly, Medicare may deny both codes or only allow payment on the code with the lowest reimbursement.

CPT® codes are published by the American Medical Association® and consist of three types or categories of five-character codes and two-character modifiers to describe any changes to the procedure. If you are looking at a single problem, such as glaucoma, both tests cannot be paid according to Medicare’s National Correct Coding Initiative (NCCI) edits; codes 92133/92134 and 92250 are considered mutually exclusive. NCCI edits prevent bundling/unbundling due to incorrectly using CPT® procedure codes and HCPCS billing codes, including combining inappropriate code combinations. While the NCCI edits do allow the use of a modifier for OCT/GDX and fundus photography, be careful and use a modifier correctly, or it may result in a rejection or denial. Depending on local policies, if both tests are necessary due to two separately identifiable conditions, you may be able to link the appropriate diagnosis code to each CPT® and add modifier 59 to the second procedure. 4. Stay Current with LCD, MAC, and Listserv Updates To ensure you are coding your eye care claims correctly, you must remain diligent with Local Coverage Determinations (LCD) and Medicare Administrative Contractors (MAC) in your area and sign up to receive payer listserv updates. 5. Don’t Procrastinate and Follow-up with Denied Claims No one likes to see a claim that’s marked DENIED in their inbox. The thought of tracking down why the claim was denied in the first place is never at the top of the favorite to-do list. The good news is that on average, two-thirds of denials are recoverable, and nearly 90% are avoidable. While tracking down why the insurance payer denied the claim in the first place is time-consuming and frustrating, the longer you wait for determining what went wrong, the more likely you won’t recover the maximum amount (or any) from the insurance payer. 6. Review Common Coding Denials and Adjustment Reasons A majority of claim denials are due to administrative errors. For example, the procedure code is inconsistent with the modifier you used or the required modifier is missing for the decision process (adjudication). Once you correct the errors, you can resubmit the claim to the insurance payer. 7. Collect Co-Pays, Coinsurance, and Deductibles Before the Patient Leaves the Office One of the fastest ways to increase your practice cash flow is to develop an upfront collection process. During check-in or check-out, if the patient’s insurance plan includes a co-pay, coinsurance, or deductible, always collect before they leave the office. Sending invoices before the due date reduces Accounts Receivable (AR) delays, helps avoid late payments, and increases your chances of getting paid on time. Open balances also create a false image of your AR.

8. Know When to Bill Routine Vision vs. Medical Insurance Many patients have both vision and medical insurance plans. While the best billing practice is to select which plan to bill based on the patient’s chief complaint and medical diagnosis, sometimes it’s more complicated. It is critical to verify both vision and medical plans before the office visit. 9. Always Complete the Interpretation and Report (I&R) for Certain Procedures Every diagnostic test that you perform requires an Interpretation and Report (I&R)—this is not optional. The I&R “interprets” the diagnostic test results and “reports” how the test affects the patient care plan: clinical findings, comparative data (change in condition), and clinical management. Don’t forget to establish medical necessity for each diagnostic test you order and perform, or the insurance payer may deny the claim as an invalid claim. If an insurance payer requests an I&R and you didn’t create one, the payer may audit your practice, which may result in penalties and interest. A good optometry EHR, should collect data for I&R using procedure-specific customizable drop-down menus and normal values. It’s critical that the I&R clearly identifies within the patient health record which tests the I&R is connected to. 10. Determine When to Use an ABN for Non-Covered Services If you suspect that the procedure or service you will provide to the patient may not be covered by Original Medicare (fee-for-service) or commercial non-Medicare plans, and the patient may be responsible for out-of-pocket costs, obtain an Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The patient must sign the ABN before you provide the procedure or service to the patient. And the ABN is invalid for any contractually obligated write-off.


Experience the Positive ROI of Outsourcing Eye Care Billing


Are you buried under a pile of paperwork? Running into billing roadblocks? Keeping up with confusing and never-ending optometry and ophthalmology billing rules, insurance payer requirements, complicated EDI processes, and managing denied and rejected claims is time-consuming and frustrating. Ready to experience a positive return on investment when you outsource eye care billing? X-Factor Healthcare LLC billing consultants will help you get started.

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