Ophthalmology Billing Services for Practices, Retina Groups, and ASCs
Eye care billing services provide revenue cycle solutions for ophthalmology coding and billing for Eye Code visits and E/M examinations and surgical procedures. Ophthalmology is one of those rare specialties where one exam could be coded twice for two payers, and the proper coding would depend on the patient’s diagnosis. Not on the type of service provided, since it defines the payment for the encounter.
UControl provides ophthalmology billing for ophthalmologists, retina specialists, cataract surgeons, and hospital ambulatory surgery centers.
UControl’s coders review the chart before the claim submission, since the diagnosis determines the payer selection while the chart determines the exam level.
UControl’s coders specialize in eye care exclusively and do not provide coding for several specialties at once.
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Ophthalmology Billing Requires Surgical and Diagnostic Coding Expertise
Ophthalmology coding has some unique rules not normally associated with general medical billing. There are two types of exam codes which refer to the same office visit and most insurance companies accept either of the two. Any biller choosing one will be undercoding their difficult cases or auditing easy cases. There are global periods of 0, 10 or 90 days which include follow-up exams in surgical operations and any follow-up exam charged within these days will be flagged as duplicates. There are three exposures which are responsible for the remaining revenue losses: insurer routing from medical to vision insurance policies, drug billing with retina injections and diagnostics tests under payer review.
Ophthalmic Modifiers and Laterality Rules
Modifiers notify the payer that two services should be separately billed when they are not supposed to be bundled. Modifier 25 allows billing of an examination along with a procedure, while modifier 24 ensures separate billing of the examination during the global period. Modifier 57 indicates the examination in which the decision of performing a major surgery was made, while modifier 59 separates two different procedures. Laterality modifiers include RT and LT on procedures and diagnostic codes, while eyelid surgery uses E1 through E4 based on the location of the eyelid. Surgery returns to the operating room during a global period using modifiers 78 and 79, while co-managed surgery uses modifiers 54 and 55.
Eye Codes vs E/M Codes in Ophthalmology
The Eye codes can be 92002 and 92004 for the new patient and 92012 and 92014 for the established patient, whereas the E/M Codes are 99202 to 99215. It is important to note that the above codes cannot be exchanged on the claim. Eye Codes have frequency edits, which means that most insurers will allow 92014 only once every twelve months, denying the next submission. In some cases, insurers will submit Eye Codes through the vision plan and E/M Codes through the medical plan, which will result in the change of the patient’s copayment and claim destination.
Downcoding Is The Exam Revenue Loss
Downcoding is a process whereby the physician chooses the code from his or her memory while conducting the consultation rather than checking from the charts to move towards the lower and safer code. The American Academy of Ophthalmology states that the disparity in the payment between an established full examination and an intermediate examination is more than thirty-eight dollars.
Use Of Just One Incorrect Modifier Can Cost Money
If modifier 25 is forgotten, the examination will get bundled in the procedure and will pay nothing at all, while incorrect application of an eyelid modifier will contradict the diagnosis laterality and hold up the claims in the audit. Modifier 25 is also one of the highest risk for compliance modifiers being audited by federal auditors.
Medical Insurance vs Vision Plan Billing
An eye patient is likely to have both a medical plan and a vision plan at once, and often, the receptionist can’t tell which one relates to a particular appointment. The medical plans take care of illness and surgery, while the vision plans include routine visits and material, like VSP, EyeMed, Spectera, and Davis Vision. It is the diagnosis, combined with the exam, that routes the case; thus, the floater complaint is covered medically and the annual visit – visually, even if the exam is identical.
What keeps appearing again and again in this dichotomy is refraction?
Medicare cannot accept the code 92015 because of the law, regardless of the rationale for it. Thus, the application will always be turned down. This particular procedure may be billed to the patient or to the vision plan, provided that there is a signed ABN in case the denial is necessary for secondary insurance coverage. We route our services according to the type of the benefits they can be submitted to.
Ophthalmology Revenue Cycle Management Services
The UControl solution is designed to manage the entire ophthalmology revenue cycle process. Every process listed here is managed through the ophthalmology prism, where the owning page link is provided for the case if the process is performed in another place of the revenue cycle.
Ophthalmology patients usually have two plans – a medical one and a vision plan. For that reason, we determine in advance which plan will be used. In addition, we perform Eye Code Frequency limits validation at this step to avoid the denial at the front desk.
Vision vs Medical Plan Coordination
We will file the disease portion with the medical insurance provider and the refraction with the vision insurance provider. Medicare regulations state that the refraction must be filed with the patient with the ABN letter.
There are separate payer-specific prior authorization requirements for cataract, retina, and glaucoma procedures. Anti-VEGF medications have per-drug prior authorization based on specific J-code and step therapy criteria. More information about prior authorization requirements can be found on our prior authorization webpage.
Laterality of the diagnosis should be consistent with the procedure modifier, which means that both right and left cataracts will have distinct ICD-10 codes. The “diagnostic eye” modifier is always attached to either RT and LT modifiers in every surgery and diagnosis billing line entered.
Documentation of Diagnostic Testing
OCT, Visual Field Test, and Fundus Photography are subject to payment only when there is a demonstrated medical necessity for the test. The repetition of the tests increases the risk of repayment. The first thing we review in regards to diagnostics is the relevant Medicare LCD.
Claim Scrubbing
Each claim goes through all the checks for NCCI edits and mutually exclusive codes prior to reaching the payer. Day-of-rule will not allow coding of both 92133 and 92134 on one eye and the scrubber identifies this code pairing at time of submission instead of denial.
Submission and Monitoring
While a clear claim requires monitoring even after submission due to the payer holding the claim without alerting the provider, we monitor every claim depending on the payer’s response. As such, any hold claim from the retina ASC will become known to us before the filing deadline.
Ophthalmology denials are centered around laterality issues, bundling and medical necessity issues, and therefore, we fix the actual issue behind the denial and not resubmit the claim itself. The general appeal process is described in the denial management section.
Reimbursements of older ophthalmology cases are compared to payer shortfalls and buy-and-bill drug reimbursement with minor rate differences resulting in big discrepancies. Please visit our A/R Recovery webpage for more information and our Provider Credentialing webpage for enrollment information.
Subspecialty Ophthalmology Billing
Every ophthalmology subspecialty has its coding specifics upon which its claims will hinge. We code according to that specific coding detail rather than the generalized template.
| ophthalmology subspecialty | coding specifics |
|---|---|
| Retina | In retina billing, we deal mostly with anti-VEGF injections; there is little room for mistakes here. The injection procedure itself is coded using 67028 on a single line while the drug is coded separately using a unique J-code. Eylea costs J0178 while Eylea HD comes to J0177 at 1 mg per unit each. Lucentis is coded at J2778 while Vabysmo is J2777 at 0.1 mg per unit – again, a unique multiplier that people often mistake for something else. Wastage comes with its own modifier where JW refers to the amount wasted while JZ confirms that the single dose vial did not waste any drug. Vials come at four figures each; drug inventory might make up half of the cost of running the practice and thus, a 2% - 3% underpayment can go for hundreds of thousands in a year. |
| Glaucoma | Glaucoma is a chronic disease code that has frequency edits. SLT is coded with 65855, where there is a global period of 10 days, and bilateral procedures that are performed on the same day are coded as 65855-50, which means billing at 150% of the allowed amount. The MIGS device implantation procedure is performed along with cataract surgery; codes include 66991 and 66989 depending on the level of complexity. The visual fields have LCD frequency edits, while a repeat visual field on a stable glaucoma case results in recoupment and not payment. |
| Cataract and ASC | Standard cataract surgery is coded as 66984 while complex cataract surgery as 66982. Complex surgery involves documented use of device/techniques, such as iris expansion ring and not the complexity of the surgery itself, hence payer recoupment in the absence of documentation of device usage in the note. Charges for facility and professional fees are split between the ASC and the surgeon. Premium intraocular lens upgrade becomes a patient payable charge by way of ABN since Medicare pays only for the conventional lens. Co-management with a referring optometrist is split between the two by use of 54 and 55 modifiers. |
| Cornea | There are separate global days and reporting postoperative guidelines for cornea transplant surgery. The issue of the benefits of keratoconus cannot be predicted because the procedure might be covered under one plan but not under another. It is not an issue of coding but rather coverage; thus, we make sure of the policy of the carrier before making the billing so that we do not run into medical necessity denials. |
| Oculoplastics | The primary issue in the reimbursement of oculoplastic surgery is whether the procedure done is a function or cosmetic procedure. Only a vision field defect can make blepharoplasty a medically necessary procedure hence, the reimbursement. Otherwise, it will be considered a cosmetic procedure and denied for reimbursement. Eyelid surgeries have E1 to E4 modifiers depending on the eyelid position. |
| Pediatric | Strabismus surgery codes depend on the number of muscles that are involved and if it is being done for a second time or not. The laws governing Medicaid change depending on which state is administering the program; hence, one treatment may be compensated differently depending on the payer. In such cases, two-state Medicaid groups are governed by two different sets of guidelines. There is a distinction between vision screening and eye examination; if they are done together, then the claim is denied. |
Ophthalmic Diagnostic Testing Billing
The primary focus of audits in this specialty will be diagnostic testing, while the defense will be the documentation. Every test has its own code and its own bundling boundary. Revenue will be lost at the boundary and not at the code itself.
92250
Fundus photography is 92250, which is considered inherently bilateral by Medicare, so there is no impact from the laterality modifier on billing. It is incompatible with posterior OCT on the same date, hence when combining it with 92134, the resulting combination leads to a bundling rejection.
A-scan
Biometry and A-scan test the eye for the power of the IOL prior to performing a cataract operation. In the case of only cataract being the diagnosis, Medicare provides coverage for just one complete eye examination and A-scan; an extra test requires a separate diagnosis
92235
Fluorescein angiography is 92235 and needs a separate dictation and report. It also includes a requirement of direct supervision and hence the physician should be in the office suite during the test
92133-92134
OCT of the optic nerve will be 92133 while OCT of the retina will be 92134. The two cannot go together with the same eye on the same day since the NCCI edit will block the codes even when the diagnoses are different, hence no modifier can unbundle the pair. When billed together, one comes out as an overpayment; hence, we bill whichever one the encounter allows.
92081-92083
Visual fields are coded 92081 through 92083, with increasing complexity, where 92081 is the limited screening while 92083 is the extended threshold test. Both are one unit and can be done on one eye or both eyes depending on payer policy and frequency limitations.
Ophthalmology Billing Compliance and CMS Audit Readiness
Ophthalmology makes it onto federal auditing lists every single year for the same structural reason. It bills expensive medication, high-volume testing, and two family types of examinations, all characteristics that lead to OIG scrutiny and comparative billing analysis. Comparative billing analysis usually leads to an audit, and the practice that cannot support the claim with its documentation is going to pay back.
We follow the compliance surface based on the structure of the risk. NCCI edits change quarterly, and so do our editing rules in order to pick up the newly created mutually exclusive codes. All claims have a documentation trail linking the code to the chart; that is the answer to an auditor. We submit the MIPS quality measures using IRIS Registry, the clinical data registry for ophthalmology maintained by the American Academy of Ophthalmology. Our coders have AAPC certification and follow AAO coding guidelines.
How UControl Improves Ophthalmology Practice Revenue
Improvement in revenue for ophthalmology involves correction of a series of errors, rather than making a single change, hence the insignificance of having a headline collection rate figure in this field. The increase in first pass rate is attributed to capturing laterality and bundling mistakes ahead of filing, hence avoiding the need for work done on aging the claims. Reduction in the number of days in accounts receivable is achieved by monitoring claims adjudication and correction of denials due to their source.
Big gains are attributed to drug line items and patient-pay line items stated above; namely, buy-and-bill reconciliation on retina injection procedures and refractions along with premium IOL upgrades which are charged to the patients. All numbers provided above come from actual account performance by the clinic and not a national average. We do not promise guaranteed collections or a certain multiple of revenues because that is not possible for any compliant billing company.
In-House vs Outsourced Ophthalmology Billing
Ophthalmology billing in-house requires the services of just one or two individuals, who in addition take care of the front office. This is not a matter of work ethic but depth of knowledge, since the same individuals cannot master the rules for retina drug coding, cataract global periods, and glaucoma frequency edits at the same time as they check in patients.
| Factor | In-House Billing | UControl Ophthalmology Billing |
|---|---|---|
| Coding expertise | Generalist staff splitting billing with front-desk duties | AAPC certified coders coded for specific ophthalmology families of codes |
| Eye Codes vs E/M | Often defaulted to one family across the schedule | Selected based on each visit and payer policy with respect to documentation |
| Anti-VEGF J-codes | Unit-basis errors and missed wastage modifiers | Pre-billing scrubbing against current NCCI edits |
| Laterality and bundling | Missing RT or LT, NCCI pairs slip through | Pre-submission scrubbing against current NCCI edits |
| Denial handling | Resubmission without root-cause review | Root cause analysis for laterality, bundling, and necessity |
| Audit readiness | Documentation gaps surface during an audit | Documentation maintained for each claim, LCD review |
Ophthalmology EHR and Practice Management Integration
We bill within the systems where an established process is already working, which means that there will be no change at the time of care delivery. We use our coders in your system and enter in your books so you have your existing processes of charting and scheduling untouched and also no data transfer is required.
Nationwide Ophthalmology Billing Services From New York
UControl maintains its base of operations in Brentwood, NY, and bills on behalf of ophthalmic practices across all 50 states. The difficulty of billing practices nationwide is in the diversity of payers as opposed to geography. A MAC policy in one state will not be the same in another, and a multi-state organization will find itself working from multiple rule books at once. We offer multi-state credentialing and coding for each claim according to its own local policy.
Medical Billing Certifications and Compliance Standards
We hold the certifications that payers and auditors look for, and our coders carry the right credentials. It’s not the most exciting part of the work, but it’s the part that keeps your claims on solid ground.
Explore Frequently Asked Questions
Yes, 92014 is the established patient complete eye exam and 92015 is refraction, which is a distinct procedure that is not covered by most medical plans, including Medicare. However, both may be performed on the same day, but the refraction will be billed to the patient or vision care plan.
Modifier 57 denotes the exam at which the decision for a major surgery took place, like cataract extraction with 90-day global period, to ensure the distinctiveness of that exam as payable service.
It will all depend on what type of Eye Code component is documented, the payer’s insurance policy, the diagnosis, and the payer’s limitation per year on Eye Codes service. The Eye Code families that pay more differ from visit to visit, hence, the decision is up to the documentation.
The injection 67028 gets charged on one line, while the medication gets charged on a different J-code. J0178 is for Eylea, J2778 is for Lucentis, and J2777 is for Vabysmo. Each gets charged separately in units. The wastage is documented using either JW or JZ modifiers. Lack of a modifier results in loss of money, especially for a four-digit cost of a vial.
66984 is a regular cataract surgery procedure code, while 66982 is a complex cataract surgery procedure code. A complex code is only applicable if there are any devices or techniques used beyond routine surgical methods, such as the iris expansion device. The complexity of the case alone is insufficient for billing purposes.
The surgery modifier 54 is attached to the surgical code to bill for surgical service only, whereas the optometrist modifier 55 is appended to the same code to bill for postoperative care. Signed transfer-of-care note and the date of service on the claim will help justify the split global fee.
92133 and 92134 are mutually exclusive on the same eye on the same day. The NCCI edit denies the two codes even if they have different diagnoses, and there is no modifier that can unbundle them, and thus one scan only needs to be charged.
Refraction 92015 is excluded by Medicare by legislation irrespective of the reason for its performance and gets billed by the patient. Most private insurers also exclude it. It can be covered under a vision plan on an annual or biannual basis.
Modifier 79 is used to indicate that the surgery on the other eye performed within the 90-day global period of the first eye surgery was unrelated to the first procedure, with modifiers indicating laterality for both eyes.
The majority of outsourced billing services charge a certain percentage of collections, and therefore the fee would depend on how much your office collects. The charge for our service will depend on the number of claims and the level of work required.