Optometry practices share the same end goal as other businesses—they want to thrive and increase cash flow. A thriving business focuses on growing revenue with top-notch optometry billing while providing excellent customer experiences.

Follow these 12 optometry billing tips to help improve patient collections and generate a healthy bottom line for your eye care practice.

1. Verify the insurance payer has approved the provider.

One of the first steps in optometric medical billing is ensuring 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 regularly follow up with insurance payers to ensure the providers are enrolled in-network when enrollment is open.

2. Verify a patient’s insurance and vision plan eligibility and benefits.

Patient insurance eligibility verification is one of the easiest ways to maintain clean claims, but verification is often the most neglected process.

Eligibility verification ensures the insurance data is correct and helps determine the amount a patient may owe (e.g., co-pays, co-insurance, and deductibles). Providing more accurate cost estimates to your patients can significantly boost patient satisfaction and save you from future claim denials.

3. Don’t confuse Medicare Advantage with Medicare.

If a patient has a Medicare Advantage plan, do not bill traditional Medicare. Medicare Advantage plans are not supplemental plans; they must cover all traditional Medicare services, including Part A (hospital insurance) and Part B (medical insurance) coverage. Most Medicare Advantage plans also cover Part D coverage (prescription drugs).

4. Keep accurate records for coding E/M patient visits.

Always keep accurate records documenting 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.

5. Use medical billing modifiers correctly to avoid rejections, denials and fines.

It’s not uncommon for optometry and ophthalmology practices to frequently misuse medical billing modifiers. For instance, on the same visit, many offices bill an OCT/GDX (CPT® codes 92133/92134) and fundus photography (CPT® code 92250). If you do not code this correctly, Medicare may deny both codes or only allow payment on the code with the lowest reimbursement.

If you look 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 Healthcare Common Procedure Coding System (HCPCS) billing codes, including combining inappropriate code combinations.

While the NCCI edits allow a modifier for OCT/GDX and fundus photography, be careful and use it 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.

6. Stay current with LCD, MAC and Listserve updates.

To ensure you are coding your eye care claims correctly, you must remain diligent with CMS Local Coverage Determinations (LCD) and Medicare Administrative Contractors (MAC) in your area and sign up to receive payer Listserv updates.

7. Don’t procrastinate, follow up with rejected and denied claims.

No one likes seeing a claim marked rejected or denied in their inbox. The thought of tracking down why the claim was denied in the first place is never at the top of your to-do list.

The good news is that, on average, two-thirds of denials are recoverable, and nearly 90% are avoidable. Tracking down why the insurance payer denied the claim in the first place is time-consuming and frustrating. The longer you wait to determine what went wrong, the more likely you won’t recover the maximum amount (or any) from the insurance payer.

8. Review common eye care coding denials and adjustment reasons.

Most 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.

9. Collect co-pays, co-insurance, 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, co-insurance, 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.

10. Know when to bill 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. Verifying both managed vision care (MVC) and medical insurance plans before the office visit is critical.

11. Complete an interpretation and report (I&R) for certain procedures.

Every diagnostic test 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 invalid. If an insurance payer requests an I&R and you didn’t create one, the payer may audit your practice, resulting in penalties and interest.

A good optometry EHR and practice management software like MaximEyes.com should collect data for I&R using procedure-specific customizable drop-down menus and normal values. It’s critical that the I&R identifies the patient health record to which tests the I&R is connected.

12. Determine when to use an ABN form 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.

Remember, the patient must sign the ABN form 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? Fast Pay Health optometric billing consultants will help you get started, and we work with ANY eye care practice management software. Request a free practice analysis today—we’re just a form submission away.

CPT® is a registered trademark of the American Medical Association®.

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12 Optometry Billing Tips to Improve Collections