Optometry and Ophthalmology services are all very specific. Because of this their coverage guidelines are also very specific. These guidelines define the types of services that can be performed and reimbursed by insurance. All insurance companies will have different service guidelines and coverage determinations, so in this case we will refer to Medicare guidelines.

The Medicare guidelines define other insurance guidelines in a very significant way, as they are basically the federal government’s determination of reasonable and customary services, which should be paid for.

Furthermore, many ophthalmology and optometry services will be covered under vision insurance, which is not your typical medical insurance. People have to buy vision insurance separately from their medical insurance plans (just like dental insurance). Some employers don’t even give the option of vision insurance.

Because of this, vision insurance plans will vary widely. They range from complete coverage of all eye related services, to one vision screening exam per year, to coverage of only medically necessary eye services performed by a physician (not an eye doctor). Still other plans will require referrals or prior authorizations before the patient can be seen by the eye doctor. It’s very important to understand all the guidelines, rules, and regulations when it comes to billing and coding eye claims.

ophthalmology and optometry also have very specific guidelines, rules, and regulations. You have to follow them all precisely for insurance to reimburse any kind of services.

Ophthalmology and optometry services are all services to the eye, including vision care and medical procedures done to the eye and ocular area. As such, for these services to be covered, they have to be performed by the right type of doctor. Medicare will only consider payment of ophthalmology or optometry services if they’re done by a provider whose scope of expertise is within these areas. In other words: eye care services must be performed by eye doctors! If they aren’t, they must be performed only with a medical diagnosis, and only when medically necessary.

Common Ophthalmology Billing Issues are:

  • A modifier is missing or invalid. 
  • An exam was in the global period, included in the major surgical procedure
  • The diagnosis did not support the procedure.
  • Code to the highest level of specificity & Code chronic conditions
  • The care may be covered by another payer per co-ordination of benefits.
  • Patient was not eligible on the date of service.
  • Invalid ID number, unable to identify insured.
  • Maximum benefits have been met.
  • Procedure is viewed as experimental
  • Missing or Invalid Billing Provider ID
  • Provider not credentialed by Payer.

Understanding Billing Modifiers:

Modifiers can aid in prompt and correct payment but can also trigger audits. Medicare and other payers continue to include incorrect modifier usage as one of the top reasons for denials and recoupments. As exams are a high-volume service for ophthalmologists, be sure you are using them correctly. There are three modifiers that are only applied when billing for E&M exam services or Eye visit codes. Modifiers -24, -25 and -57 should never be applied to another service rendered such as tests or surgeries. Each tells the payer why the exam is being submitted, which impacts reimbursement for the physician

Ophthalmology and optometry services are very restricted per diagnosis, frequency, and by provider.

It’s very important to understand all of the guidelines, rules, and regulations when it comes to billing and coding eye claims. If you have strict attention to detail, like making sure all your t’s are crossed and i’s are dotted, then the fields of ophthalmology and optometry billing or coding may be for you. These offices are also not usually as busy as medical doctor’s offices – the slower pace may also be a fit for you.

Ophthalmology medical billing is a highly specialized business, make sure you have CareMB experts doing it for you