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5 Billing Tips for Ophthalmology Facilities to Maximize Reimbursements

September 22, 2022

Success in ophthalmology medical billing relies on efficient and timely collections. Submitting consistently clean claims and getting paid on time can help keep your ophthalmology practice afloat. 

The following are medical billing tips that will help your facility maximize your revenue flow:

1. Understand the Ophthalmology Billing Process and What Is Required for Each Claim

Ophthalmology is unique because it is the only medical field that uses two different code sets: E/M codes and eye codes. Knowing which code to use is crucial. In-depth knowledge of subspecialties (e.g., retina, pediatric, glaucoma, ocular plastics) is also necessary for accurate medical billing in ophthalmology.

Choosing the right ophthalmology medical billing codes will depend on the following factors:

  • Payor rules and guidelines
  • Payor’s medical necessity requirements
  • Reimbursement rates
  • Elements of exam performed

Other factors to consider when choosing the correct code include:

  • E/M codes are only used when the visit includes a medical element. If no medical element was involved, an eye code should be used.
  • Eye codes have frequency edits while E/M codes don’t. 
  • Insurance payor documentation for E/M codes is standard across all payors, while the required documentation for eye codes may vary.

2. Make Sure All Information Is Accurate and Up-To-Date on Patient Charts

It is the provider’s responsibility to verify patient information upon each visit. Old ID numbers and insurance cards may not be recognized by the insurance company or payor. While an unintentional typo in name or birthdate may seem minor, if the patient information does not match the health plan on file, the claim may be denied. Being aware of the consequences of simple errors is crucial as they not only slow down the medical billing process but will also impact your bottom line.

Manually entering information can also result in medical billing and coding errors in ophthalmology, especially if the staff members are not properly trained in data entry techniques.

coronis health medical professional discussing ophthalmology medical billing services with patient

Examples of common mistakes that cause denied claims due to incorrect patient information include:

  • Misspelled first or last name
  • The use of a nickname vs a legal name
  • Patient’s birthdate on the claim does not match the birthdate on the health insurance plan
  • ID number is missing or invalid
  • Relationship to the insured is not valid

3. Use Correct Ophthalmology Modifiers to Indicate the Level of Service Provided

Ophthalmology modifiers are the best way to accurately describe a service. When used incorrectly, these modifiers can lead to denied medical claims. Examples of frequently used modifiers include:

  • RT – right eye
  • LT – left eye
  • E1 – upper left eyelid
  • E2 – lower left eyelid
  • E3 – upper right eyelid
  • E4 – lower right eyelid
  • 24 – Unrelated E/M service (or eye visit code) by the same physician during postoperative period
  • 25 – Separately identifiable E/M service provided by the same physician or other qualified healthcare professional on the same day of the procedure or other service
  • 51 – Multiple procedures performed on the same day during the same encounter
  • 59 – Procedures/services not normally reported together but appropriately billed under the circumstances
  • 79 – Unrelated procedures or services performed by the same physician during the postoperative period 

Billers must always pay attention to using the right modifiers, documenting services clearly and accurately, and meeting all guidelines to avoid denials, which will affect reimbursements and cash flow.

4. Bill Promptly to Ensure Timely Reimbursement From Insurance Companies

Every claim is given a specific amount of time for submission. Failure to submit a claim before its due date may result in a facility shouldering the cost. In most cases, facilities neglect to file claims on time due to incomplete or lost bills (charge tickets). 

Even if claims are correct and complete, they can still be denied when submitted after their corresponding filing date has passed. It is best to submit claims promptly, as soon as possible after the services are rendered, so it doesn’t slow down your revenue cycle.

coronis health ophthalmology medical biller working at computer

5. Stay Organized and Keep Track of A/R and Outstanding Balances

You need a solid organizational system. Medical coding and billing for ophthalmology should allow a facility to obtain data quickly and efficiently for themselves, their patients, and other clients. EMR software is one tool that helps providers manage records easily with its automated clinical workflows.

Another way to improve efficiency and lower administrative costs is by monitoring A/R and outstanding balances. A/R follow-up ensures that facilities have a way to recover overdue payor or patient payments. A/R follow-up responsibilities also include keeping track of denied claims and appealing them, exploring partial payments, and reopening claims to receive maximum reimbursement. 

Questions About Outsourcing Your Ophthalmology Medical Billing? Contact Coronis Health Today!

Coronis Health is a global revenue cycle management company offering specialized solutions to healthcare practices and facilities. By using industry-leading technology combined with high-touch relationship building, Coronis Health allows healthcare practitioners to focus on patient care, maintain financial independence, and cultivate financial success.

Choosing the right partner for ophthalmology medical billing services is critical to ensuring a healthy revenue cycle for your facility. How well your claims are processed will determine how financially strong and independent your facility will be. To learn more about how you can optimize your RCM medical billing for ophthalmology and how you can benefit from outsourcing your medical billing, contact Coronis Health and request your free financial checkup today.

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