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Billing in Ophthalmology: How to Stay Compliant and Get Paid

October 17, 2022

The ophthalmology medical billing landscape is an ever-changing scene that consumes time and resources. Compliance and accurate billing are required to receive timely reimbursements and boost the revenue cycle.

At Coronis Health, we help facilities remain 100% compliant. We stay up to date on the latest rules, regulations, and coding requirements so you can focus on patient care. Coronis Health provides medical billing and coding for ophthalmology with a personalized touch so that our experts know what regulatory changes are coming, when they will be implemented, and how to prepare your facility.

Understand Billing and Coding Guidelines for Ophthalmology Medical Services

Medical coding and billing for ophthalmology requires two different code sets: E&M codes and eye codes. Medical billing and coding for ophthalmology fall under chapter 11 of CPT codes (evaluation & management) coding guidelines ranging from 90000 – 99999.

Ophthalmology medical billing also requires knowledge of subspecialties, including:

  • Pediatric
  • Retina
  • Glaucoma 
  • Ocular plastics
coronis health ophthalmologist testing patient's eyesight

There are official coding guidelines for ophthalmology medical billing codes as stated by CMS. Examples are:

  • E&M codes should not be reported separately. 
  • The E&M services include general ophthalmological services. Special ophthalmological services represent specific services not included in a general or routine ophthalmological examination. Special ophthalmological services may be reported separately as they are recognized as significant, separately identifiable services.
  • For procedures requiring the intravenous injection of dye or other diagnostic agents, insertion of an intravenous catheter and dye injection is integral to the procedure, and therefore, these procedures are not separately reportable. 

Ensure Your Facility Is Using Correct CPT Codes and Modifiers for Ophthalmology Services and Procedures

coronis health microscope used for ophthalmology

Ophthalmology services having two sets of codes may add flexibility to your billing, but it can also make the process confusing. To choose the right code, you must consider these decision factors:

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

The ophthalmology CPT medical billing code range for Ophthalmology Services and Procedures 92002-92499 is a medical code set maintained by the American Medical Association.

Ophthalmology Services and Procedures:

92002-92014General Ophthalmological Services and Procedures

92015-92287Special Ophthalmological Services and Procedures

92310-92326Contact Lens Services

92340-92371Spectacle Services (Including Prosthesis for Aphakia)

92499-92499Other Ophthalmological Services or Procedures

Understand Common Insurance Denials and How to Appeal Them

The following are common reasons for denied claims:

  • Missing or invalid modifier
  • Diagnosis does not match the procedure performed
  • Wrong code used when the global period has expired
  • Care is covered by another payer (per coordination of benefits)
  • No verification of patient information (patient not eligible on the date of service)
  • Invalid patient ID number (unable to identify insured)
  • Maximum benefits have been met
  • Recommended procedure is viewed as experimental and invalid

While appealing denials is not always successful, there are factors you can take into account to help ensure a smoother process and improve your revenue cycle management (RCM) with medical billing for your ophthalmology practice:

  • To successfully appeal a denial, you must first recognize it and then figure out what the reason for the denial is
  • Ensure that the correct form is filed. The CMS has a form for appealing Medicare claim denials known as the Medicare Redetermination Request Form. Make sure all information is complete and accurate. Specific data in the report serves as important proof of the validity of your claim. Every piece of documentation is necessary in making your case more compelling.
  • The process does not end with submitting the appeal. You must confirm if the appeal has been reviewed and then follow up in 30 days.
  • Maintain a record of all your denied claims to compare your reimbursement rate with your denial rate, helping you keep track of your bottom line.

Stay Up to Date On New and Emerging Ophthalmology Billing Regulations

New medical technologies and techniques are constantly being introduced in healthcare, and ophthalmology services are no exception. According to CMS updates, effective January 1, 2022, ophthalmology will undergo critical changes in the billing and coding system. Facilities and their revenue cycle management teams must adapt to these changing trends of code usage because submitting clean claims and getting paid on time is what will keep your ophthalmology facility afloat.

The Easiest Way to Stay Compliant and Ensure Timely Payments? Partner With Billing Experts at Coronis Health

Medical billing for ophthalmology is not exactly a walk in the park. Opportunities for errors are common. These missteps will impact your bottom line or worse, get you into trouble with auditors. As the complexity of ophthalmology billing and coding increases, it could get more challenging for your facility’s in-house staff to keep up with the workload while remaining compliant.

Consider partnering with a revenue cycle management company with experience specifically in ophthalmology medical billing services, so you will benefit from their vast resources and expertise in this area. 

Coronis Health features top medical billers in the country pooling their global resources to bring customers the best in medical billing and revenue cycle management. With over 40+ years of combined experience in various niches including ophthalmology offices of all sizes, Coronis offers customers tailored solutions and high-touch relationships you won’t find at a “Big Box” medical billing company. 

While most billing companies just submit claims, Coronis Health’s process allows us to identify and correct the root cause of denials, resulting in increased revenue for your facility. Our practice managers remain constantly vigilant and compliant amid the changing chorus of governmental/carrier billing and documentation regulations and compliance requirements. It is this proactive approach to billing that helps our clients get results. We ensure your collections are easy to manage and denials are kept to a minimum.

To learn more or to request your free financial checkup, contact Coronis Health today.

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