Ophthalmology Medical Billing Guidelines

Touseef Riaz

May 2, 2022

Ophthalmology Medical Billing Guidelines

This study or field of medical conditions is related to the human eye. It deals with the diagnosis, medical and surgical treatment of eye-related disorders. Significant ophthalmology services include vision care and all other conditions related to the eye. Like every other healthcare specialty, medical billing for ophthalmology is a critical component. When it comes to medical billing of ophthalmology, it requires two different code sets; E&M codes and eye codes. In-depth knowledge of the following subspecialties is also necessary for ophthalmology medical billing; they include:

  • Retina
  • Pediatric
  • Glaucoma
  • Ocular Plastics

Medical billing and coding for ophthalmology are complicated as it uses two different code sets; therefore, choosing the correct code is crucial. New techniques and technologies are being introduced in healthcare to increase life expectancy. This is why proper and accurate medical billing is required to improve the revenue cycle of any ophthalmology practice. However, there are several challenges associated with ophthalmology medical billing.

 Ophthalmology Medical Billing Guidelines -ucontrolbilling

Ophthalmology Medical Billing Codes:

The ophthalmology CPT medical billing code set is maintained by the American Medical Association (AMA). The code range for ophthalmology procedures and services is 92002-92499. Following is its further categorization:

  • 92002-92014: General Ophthalmological Services and Procedures
    • 92002-92004
      • New Patient General Ophthalmological Services and Procedures
    • 92012-92014
      • Established Patient General Ophthalmological Services and Procedures
  • 92015-92287; Special Ophthalmological Services and Procedures:
    • 92015-92145
      • Ophthalmological Examination and Evaluation Procedures
    • 92201-92260
      • Ophthalmoscopy Procedures
    • 92265-92287
      • Other Specialized Ophthalmological Services and Procedures
  • 92310-92326: Contact Lens Services:

Some of the CPT codes belonging to this category are listed below:

  • 92310:
    • The provider performs all components of contact lens prescription and fitting for both eyes except when the lens of the eye (aphakia) is absent due to prior cataract surgery.
  • 92311:
    • The provider prescribes and fits a contact lens for one eye, which is aphakic; the patient has had cataract surgery.
  • 92313:
    • Prescription of contact lenses to include the optical properties, improving the patient’s vision, size, and shape, contributing to proper fit in the eyes. Instructions regarding adapting the new lenses are also provided.
  • 92316:
    • The provider prescribes a corneal contact lens for both eyes in a patient with aphakia. He supervises the fitting of the lenses by an independent technician.
  • 92340-92371; Spectacle Services (Including Prosthesis for Aphakia):
    • 92352:
      • The fitting of eyeglasses with one specified focal length for patients who have undergone removal of the native crystalline lens, i.e., those who have had cataract surgery.
    • 92354:
      • The provider fits a magnifying lens on the eyeglasses to improve a patient’s near vision for tasks like reading.
    • 92370:
      • The provider makes adjustments and or repairs to eyeglasses in a patient who does not have aphakia, the absence of a lens in the eye.
  • 92499-92499; Other Ophthalmological Services or Procedures:
    • 92499:
      • To report ophthalmological procedures that do not have a specific code.

Ophthalmology coding guidelines:

Medical coding and billing for ophthalmology falls under chapter 11 of CPT codes (evaluation & management) coding guidelines ranging from 90000 – 99999. Following are some of the official coding guidelines for ophthalmology billing codes:

  • As mentioned earlier, CPT Codes from 92002-92014 are the general ophthalmological services. When reporting E&M codes, these codes should not be reported separately. The E&M services include general ophthalmological services.
  • Special ophthalmologic services represent specific services not included in a general or routine ophthalmological examination. Special ophthalmological services may be reported separately as they are recognized as significant, separately identifiable services.
  • For procedures requiring the intravenous injection of dye or other diagnostic agents, the insertion of an intravenous catheter and dye injection is integral to the procedure. These procedures are not separately reportable. The following are not separately reportable CPT codes:
    •  36000 (Introduction of a needle or catheter)
    •  36410 (Venipuncture)
    •   96360-96368 (IV infusion)
    •   96374-96376 (IV push injection)
    •  Selective vascular catheterization codes
  • Selective catheterization and injection procedures for angiography are included in CPT codes 92230 and 92235.
    • CPT codes 92230 and 92235: Fluorescein angioscopy and angiography).
  • CPT code 92071 shall not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea.
    • CPT code 92071: Fitting of contact lens for treatment of ocular surface disease.
  • Fundus photography and scanning ophthalmic computerized diagnostic imaging codes are generally mutually exclusive of one another. This means to evaluate fungal disease, healthcare providers will either use one procedure/technique or the other. However, there are limited clinical conditions where both techniques are considered medically reasonable or necessary in the same eye. So, both the CPT codes may be reported appending modifier 59 or XU to CPT code 92250 in these situations.
    • Fundus photography (CPT code 92250)
    • Scanning ophthalmic computerized diagnostic imaging (e.g., CPT codes 92133, 92134).

Tips for improving Ophthalmology Medical Billing:

Challenges faced by medical billing of any healthcare practice directly impact the revenue cycle and reimbursements. Along with that, they also affect the growth of ophthalmology practice. Any medical billing and coding errors can lead to claims being denied or rejected, leading to lost payments and possible audits. Following are some of the tips and factors for improving medical billing for ophthalmology practices:

  • Evaluation and management (E/M) codes & Eye codes:

Ophthalmology billing comprises two code sets, unlike other healthcare specialities. Correct ophthalmology medical billing requires choosing the right code. This depends on the following factors:

  • Insurance payer’s guidelines and rules
  • Payer’s medical necessity requirements
  • The reimbursement rate of the codes being considered
  • Elements of the exam performed

Listed below are some additional factors for choosing the correct code for your practice:

  • Check the diagnosis Code(s): when it comes to eye codes, they are more limited. The specific codes can vary based on the payer’s requirements; however, E/M codes do not share these similar restrictions.
  • E/M codes should only be used if the visit includes any medical element. In case there is no medical element involved in the visit, e.g., strictly visual, an eye code should be used.
  • Eye codes have frequent edits, which is why checking the patient’s medical history is essential. For instance, the 92014 billing code is limited to once per 12-month period per patient. In contrast, E/M codes don’t have any of these frequency edits.
  • Insurance payer documentation requirements for E/M codes are standard across all payers. However, for eye codes, the required documentation may vary.
  • Out-of-the Network Billing:

Be careful with this type of billing, as various healthcare providers end up with it. However, UControl Billing can help your healthcare practice grow and reduce errors in medical claims.

Following are some of the standard/best practices for out-of-network billing:

  • Be transparent with the patient regarding the healthcare practice’s out-of-the-network billing status.
  • To avoid balance billing, provide the patients with estimated payments upfront.
  • The charge payment on medical claims used to calculate patient payments should be the same on all the claims.
  • Payer requirements and updates in guidelines:

Documentation and other guidelines regarding ophthalmology medical billing may vary among the payers as well as Medicare. This is why providers are required to bill a code and provide documentation the way they (payers) want. Submitting a clean claim to the insurance provider requires following the payer’s guidelines and requirements.

  • Ophthalmology billing for diagnostic tests:

Billing diagnostic tests for ophthalmology billing is always under the close eye of the auditors. This is why violating the rule and not following the guidelines can easily result in claims being denied and possible audits. In order to avoid that, your ophthalmology practice should:

  • Use the correct CPT codes

  • Use the right Modifiers
  • Follow the payer’s guidelines
  • Ensure timely submissions
  • Complete and correct documentation

Issues in Ophthalmology Medical Billing:

Like every other healthcare speciality, ophthalmology billing also faces some issues regarding coding and billing. Following are some of the common ophthalmology billing-specific issues:

  • Upcoding:

Upcoding is an unethical medical billing practice that involves billing more expensive codes. This practice results in higher reimbursements and is Medicare abuse.

In ophthalmology billing, reporting visual field testing separately with general ophthalmological service is considered upcoding. This is because visual field testing is already a part of general ophthalmological services (92081-92083).

  • Incomplete documentation:

The documentation must contain the medical necessity behind the provided treatment. For instance, when reporting fundus photography:

  • Keep a check on your frequency: as some insurance payers only allow or approve a fundus photography procedure:
  • Once per 12 months for slowly evolving disorders
  • Twice per 12 months for rapidly evolving disorders
  • Report the medical necessity behind this procedure in the documentation
  • Incorrect Modifier:

Using an incorrect modifier for ophthalmology medical coding can result in the claim being denied, affecting reimbursements. For ophthalmology, the practice should know where to use the modifier TC. This means that modifier TC can only be used once, even if an A-scan is done on both eyes. Note that modifier TC (technical component) is bilateral, whereas the professional component is unilateral. The calculations are typically separately performed on each eye before surgery by the physician. Therefore, the professional component can be billed, and modifier 50 can be used.

All the above-mentioned errors and mistakes in medical coding can be avoided by outsourcing the services to a well-reputed medical billing company. Some of the major benefits of outsourcing include:

  • Lesser errors in medical claims
  • A team of highly experienced professionals in medical billing
  • More focus on providing safe and quality patient care
  • Lesser claim denials and a higher clean claim rate
  • Faster payments and a higher reimbursement rate
  • Improved revenue cycle

Introduction to Ophthalmology:

Medical conditions and disorders related to the eye are included in ophthalmology. Diagnosis and surgical treatments for these medical conditions are provided by the ophthalmologist. Following are the conditions treated by the ophthalmologists:

  • Glaucoma
  • Corneal conditions
  • Retinal Conditions
    • Diabetic retinopathy
    • Macular degeneration
  • Pediatric eye conditions and disorders
  • Neurological cases like:
    • Optic nerve issues
    • Double vision
    • Vision loss (few kinds)
    • Abnormal eye movements
  • Complex surgical procedures like:
    • Reconstructive surgery
    • Advanced vision repair

An ophthalmologist deals with the diagnosis, prevention, and treatment of almost all conditions and disorders related to the eye. It includes conditions related to the eye as well as vision-related issues.

Frequently Asked Questions (FAQs)

  1. What is ophthalmology medical billing in medical billing?

Ophthalmology deals with the diagnosis, medical and surgical treatment of eye-related conditions. Medical billing and coding for ophthalmology are complicated as it uses two different code sets; therefore, choosing the correct code is crucial. Two code sets include E/M codes and eye codes.

  1. What are common ophthalmology medical billing errors?

Errors in medical coding can lead to claims being denied and lost payments. Reporting visual field testing separately with general ophthalmological services is considered upcoding. Common mistakes in ophthalmology billing include the use of incorrect modifiers, absence of medical necessity in the documentation, and upcoding.

  1. What does ophthalmology medical billing mean?

The ophthalmology CPT medical billing code set is maintained by the American Medical Association (AMA). New techniques and technologies are being introduced in healthcare to increase life expectancy. This is why proper and correct medical billing is required to improve the revenue cycle of any ophthalmology practice.


  • https://www.ophthalmologymanagement.com/issues/2022/february-2022/coding-amp;-reimbursement

You May Also Like…


Submit a Comment

Your email address will not be published. Required fields are marked *

Ready To Get Started?

Pin It on Pinterest