Published in Non-Clinical

Medical Optometry Practice – Understanding Billing and Coding

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9 min read

Starting a medical optometry practice begins with understanding how to bill and code. Here is what you need to know to get started.

Today more than 86% of US citizens have medical insurance including more than 50 million Medicare beneficiaries.
The fastest way to grow an optometric practice is to provide comprehensive medical care for all your patients.

Three initial steps to build a medical optometric practice are:

  1. Review Medicare allowables to establish exam fees
  2. Treat everything your license allows and charge for every procedure performed
  3. Invest in technology (Retinal Camera and OCT Scanning Laser is a great place to start)
It is also critical that you learn how to explain to patients how they can use their insurance to offset the cost of eye care. You don’t have to be an insurance expert but you do need to understand enough to explain the difference between routine and medical plans as well as what copays to collect and what fees may be applied to the patient’s deductible if they have one. Typically, the chief complaint and diagnosis drive the exam, therefore if the primary diagnosis is medical and addresses the chief complaint then it is will most likely be billed as a medical exam.

Before you start a medical optometric practice, you need to do the following:

  1. Select insurance panels and credential for them
  2. Decide how to submit your claims
  3. Learn how to properly code and document exams and understand what procedures to perform
Before you begin the credentialing process you must first decide how your practice will be set up legally. Most likely you will need to confer with a lawyer or accountant to decide whether you will be a solo proprietor or corporation.
Once that is decided you have established a location to practice then you may begin the credentialing process starting with the following:
  • Step 1: Apply/receive state license
  • Step 2: Apply/receive Individual NPI #
  • Step 3: Apply/receive Tax ID #
  • Step 4: If incorporating apply for Group NPI # after receiving Tax ID #
Credentialing can be a time-consuming process and is often best performed by someone with experience. If you need assistance feel free to contact Kenny Meyer at and he can help you credential for both routine and medical plans.
When you credential for Medicare I highly recommend you become a participating provider who accepts assignment as this will encourage Medicare patients to see you because their out-of-pocket expense will be lower.
How you submit your claims is critical in receiving timely and efficient reimbursement from medical insurance carriers. The most efficient way to submit claims is to use an EHR, clearinghouse and experienced medical biller.
Excellent cash flow in an optometric practice is dependent on efficient and accurate claim submission and should never be entrusted to an un-trained or inexperienced staff member.

Coding and billing are two separate activities most efficiently performed by different individuals within a practice.

Billing is best performed by staff or out-sourced to well-trained billing specialists whereas the coding should always be performed by the doctor. It is the doctor’s responsibility to become educated on proper and ethical coding procedures to ensure all claims are coded correctly.
That education starts with understanding which office visit codes to use.
Optometrists have the luxury of being able to utilize both the 92xxx General Ophthalmological Service codes and the 99xxx Evaluation and Management codes. Only eye doctors can use the 92xxx codes and they can be used for both medical and routine exams. The 99xxx codes are utilized by all health care professionals and are specific for medical only exams with more specific guidelines you must follow. Both are easy to use once you understand how to use them.
99xxx codes are determined by the documentation of the health history, exam elements, and medical decision-making. Therefore, you must first establish what level of each you performed during the exam. The health history has four different levels depending on how much detail was documented on the Chief Complaint, HPI History of Present Illness, Review of Systems and Past, Family and Social History.
The elements of the exam include the following:
  1. Visual Acuity
  2. Visual Fields
  3. Adnexa
  4. EOM Motility
  5. Pupils & Irises
  6. Bulbar/Palpebral Conjunctiva
  7. SLE – Cornea
  8. SLE – Lens
  9. SLE – Ant Chamber
  10. IOP
  11. Optic Nerve
  12. Posterior Segment
  13. Orientation/Mood and Affect
It is important to note that when performing a medical exam, you only perform those elements of the exam necessary to diagnose and treat the problem the patient is presenting with today. It is ok to perform the same tests during a routine exam on every patient but that strategy may not be utilized while performing a medical exam. Instead, use your professional judgment to decide what exam elements you choose to perform.
The medical decision-making may be broken down into 4 levels including straight-forward, low complexity, moderate complexity, and high complexity. 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 the patient who presents with 3 or more new problems and in that case, a high complexity decision-making would be appropriate.
The 92xxx codes have fewer guidelines to follow and can be broken down into two levels comprehensive 92004/92014 and intermediate 92002/92012. The comprehensive exam often includes a retinal evaluation and typically is not performed more than once year. The 92002/92012 are more often used for anterior seg issues or follow up visits.
In addition to office visit codes, there are also procedure codes you must familiarize yourself with such as bilateral procedures 92250 Fundus Photos and 92083 Threshold Visual Fields. Bilateral procedures have one fee associated with them whether you perform the procedure on one or both eyes. Unilateral procedures like 65222 Corneal Foreign Body Removal allow a fee to be charged for each eye when performing the procedure on two eyes.

Insurance billing also involves rules you must follow to properly identify patients and provide appropriate privacy measures for your patients.

In order to share your clinical information with an insurance carrier, you must have either the patient or the under-aged patient’s guardian sign a Signature on File form. Otherwise, you cannot be reimbursed by the carrier if you don’t submit a claim with the necessary codes for reimbursement and you can’t share that information without the patient’s permission.
Insurance carriers allow a higher fee for new patients versus established patients so you must determine for every patient whether they are new or established. Medicare along with many other carriers define a new patient as one who has not been seen by you or a partner in the past 36 months and any patient seen within the last 36months is considered an established patient. Most carriers have timely filing deadlines that you must follow for full reimbursement.
Medicare allows you to submit a claim within one year of the date of service to receive full reimbursement, however, if you submit a Medicare claim after 12 months then it will be denied and you may only collect from the patient the 20% of the exam fee that Medicare does not cover. Other carriers may have timely filing deadlines as short as 60 days from the date of service so be sure to determine the deadline and submit your claims accordingly.
One fact you can count on for medical billing is that there are as many guidelines to follow as there are insurance carriers and even then the same carrier may have different rules apply depending on which state you practice in.
Staying in the know requires an on-going focus on reviewing the insurance carrier policies and requires you have an experienced and well-trained billing specialist working for you. In addition, doctors must also invest time in learning the coding guidelines you must follow to properly code your exam.
Antonio Chirumbolo, OD
About Antonio Chirumbolo, OD

Antonio Chirumbolo, OD is the Director of Client Services at CovalentCreative. He completed his optometry degree at the SUNY College of Optometry in 2013. Antonio is passionate about digital media, marketing, and advertising and in his free time still practices optometry in Pittsburgh, Pennsylvania.

Antonio Chirumbolo, OD
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