There are three extremely common mistakes in optometry billing and coding: mixing up routine vs. medical exams, using modifiers incorrectly, and submitting claims prior to being fully credentialed. Each of these can result in a denied claim—or even worse, an audit.
1. Routine vs. Medical
It is important to understand the difference between medical and routine exams to ensure you receive full reimbursement for your services. Distinguishing the difference between the two exams begins with knowing there are more similarities than differences.
Typically, the chief complaint and diagnosis drive the exam. Therefore, if the primary diagnosis is medical and addresses the chief complaint, then it will most likely be billed as a medical exam. That said, don’t assume that every patient complaining of blurry vision has a refractive issue.
Often, blurry vision has an underlying medical condition resulting in a medical ocular exam being performed instead of a routine exam being submitted to a vision plan. The case history performed on a new patient should not vary for a medical exam versus a routine exam since it is performed before you see the patient and the type of eye exam has not been established yet. The elements of the exam are similar between medical and routine exams with one major difference.
When performing a medical exam you must choose the exam elements necessary to diagnose and treat the patient and perform only those tests. Many doctors will perform the same exam elements as part of a routine eye exam on every patient, which is not acceptable for a medical ocular exam because it may incorrectly raise the level of exam being coded for visit. The decision-making process is also different for a medical exam versus a routine exam, since a routine/refractive exam requires little or no medical decision-making and a medical exam typically includes either low or moderate medical decision-making.
Medical decision-making may be broken down into 4 levels:
I prefer to simplify the decision-making process by focusing on two levels: the low complexity of follow-up visits and moderate complexity for the exam involving a new problem presentation. In this manner, it is quick and easy to establish the level of decision-making—but keep in mind that occasionally you may see a patient who presents with three or more new problems. In that case, high complexity decision-making would be appropriate.
2. Using Modifiers Incorrectly, Resulting in Denied Claims
Modifiers are the best way to most accurately describe a service, but when used incorrectly they can lead to denied medical claims. Frequently used modifiers for eye exams include:
RT/LT for right and left eye/lid as well as E1-E4 modifiers to differentiate right and left as well as inferior and superior lids.
-24 modifier is used when a doctor performs an office visit during the global period of an unrelated procedure. An example is when a patient had cataract surgery performed within the past 90 days and presents with an unrelated ocular issue in the other eye.
In order to be reimbursed for the office visit, you must add a -24 modifier to the office visit when submitting a claim to the insurance carrier.
-25 modifier is used when performing two separate and unrelated procedures on the same day.
-55 modifier is necessary when you co-manage a surgical procedure with a surgeon and only perform the post-op care.
In addition, if you are performing post-op 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.
3. Improper Credentialing or Submitting Claims Prior to Being Fully Credentialed
The third most commonly made error involves improper credentialing, or submitting claims prior to being fully credentialed for an insurance panel.
It is critical before credentialing that you decide if you will be a sole proprietor or corporation.
I strongly encourage you to seek proper legal advice from an attorney before beginning the credentialing process.
It is just as essential that you not see patients on a particular plan until your application has been processed and approved. In the case of Medicare, where you can backdate claims, you must establish a starting date prior to seeing Medicare patients. The starting date is typically the date they begin processing your application.]
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