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Payment Denied! Common Optometric Billing and Coding Mistakes

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6 min read

In many cases, billing and coding mistakes are responsible for denial. Learn some of the most common mistakes optometry practices make and how to avoid them.

Payment Denied! Common Optometric Billing and Coding Mistakes
As optometric practices increase their medical eyecare services, it is critical for practice revenue flow that insurance claims filed for services be paid promptly. The last thing any billing and coding staff wants to see is Explanation of Benefits (EOB) forms which state that payment for services has been denied or reduced.
Once a claim is denied, it then becomes important for the staff to discover the reason for denial and resubmit a corrected claim. Unfortunately, many practice owners have found that their staff does not take the time to file a corrected claim and follow it through to payment, thus resulting in inflated accounts receivable and decreased practice income.
In some cases, claims are filed correctly but improperly processed. However, in many cases, billing and coding mistakes are responsible for denial. This article will review some of the most common billing and coding mistakes practices make.

Using “unspecified” ICD-10 optometric diagnosis codes

The main purpose of the ICD-10 coding system is to provide more detailed information about a patient’s medical problems for public health tracking purposes. While the prior ICD-9 code system may have had a code for something like moderate diabetic retinopathy, the ICD-10 system code for that retinopathy will tell us the type of diabetes, the eye(s) involved, severity, and whether DME is present—all with one code number. This “specificity” is important for billing purposes.
In 2015, when ICD-10 was first used in the US, CMS and other insurers stated that the ICD-10 codes submitted for claims should be coded to the highest level of specificity and that, with rare exception, no “unspecified” codes would be accepted. For example, there are four codes for age-related nuclear cataracts. Three specify the eye(s) involved and one, H25.10, is for “Age-related nuclear cataract, unspecified eye.”
If the unspecified code is submitted, it implies the optometrist did not take the time to even note which eye is involved and puts into question the Medical Necessity for the exam, which is required to file a claim.
While many doctors rely on their EMR software to select the proper ICD-10 codes, it is the responsibility of the doctor and billing staff to assure that no “unspecified” codes are submitted.

Not reading and understanding LCDs or NCDs for optometry

These are published by regional Medicare carriers and CMS, respectively. These are available both on the regional carriers and CMS websites and are also easy to find with Google searches. The LCDs (Local Coverage Determinations) and NCDs (National Coverage Determinations) refer to specific CPT codes for services, such as retinal photos, OCT testing, and visual fields. They provide lists of ICD-10 diagnosis codes for which the procedures are approved, information about test frequency, proper test documentation, and other information. These guidelines are often followed by commercial insurers as well.
While they provide much good information, there are always exceptions. For example, for retinal photos (92250), the NCD list of approved codes includes E10.9 and E11.9 for patients without diabetic retinopathy. However, if you read the LCD carefully, there is a section which states that retinal photography of normal retinas is not Medically Necessary and thus not a payable service.
It is also important to pay attention to the frequency approved for certain tests. If a test is done too often, payment may be denied. For example, for patients who are glaucoma suspects or have mild glaucoma, fields are only approved once per year. Patients with moderate glaucoma are approved for two fields per year.

Violating CCI (Correct Coding Initiative) guidelines

These detail which tests and procedures may be provided on the same date of service. For example, CCIs indicate that retinal photos and OCTs should not be done on the same date, but allows photos and visual fields on the same day.

Multiple Procedure Payment Reduction (MPPR)

This policy, followed by most insurers, reduces the reimbursement for doing more than one test/procedure on the same date of service (DOS). Many offices will do several different tests/procedures on the same DOS. While convenient for both the patient and practice, most offices do not realize that when multiple tests/procedures are done on the same day, the highest reimbursing code is reimbursed at the full allowable fee, but the fees for subsequent tests/procedures is reduced by at least 20% and, theoretically, possibly up to 100%.
An example would be punctal plugs where multiple plugs are inserted on the same day. The first plug is reimbursed at 100% of the allowable, but each subsequent plug is reimbursed at 50% off.

Common optometric coding mistakes lead to costly errors

In conclusion, it is important for eyecare providers and their billing staff to be aware of different aspects of testing, billing and coding guidelines, and restrictions in order to both file correct claims to insurers the first time and also understand their practice habits which may result in receiving reduced fees for their services. If they do not pay attention, practice expenses for staff time needed to resubmit corrected claims, reduced fees for multiple tests/procedures, and other improper billing habits may result in a significant decrease in practice income.
Thomas Cheezum, OD, CPC, COPC
About Thomas Cheezum, OD, CPC, COPC

After 40 years in clinical optometric practice, Thomas Cheezum has dedicated the last few years to the areas of medical billing, coding, and record keeping. He is a Certified Professional Coder and a Certified Ophthalmology Professional Coder. He performs records audits for offices and lectures on the topics of billing, coding, and record keeping.

Thomas Cheezum, OD, CPC, COPC
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