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Coding for Ophthalmology Medical Billing: What You Need to Know

September 22, 2022

Ophthalmology medical billing, like other medical billing, is essential to ensure that an eye care facility remains profitable and viable to continue caring for patients. Because eye care is unique and unlike other specialties, it requires a strong foundation of knowledge to understand the intricate nature of ophthalmology medical billing services. 

From basic vision care to the complex subspecialties, such as retina care, pediatrics, glaucoma, and ocular plastics, the medical billing team at Coronis Health understand the differences within the domain of ophthalmology billing. 

The Different Types of Codes Used for Ophthalmology Medical Billing

Ophthalmology medical billing codes fall into two categories – eye codes and evaluation and management (E&M) codes. Understanding the differences between the two is critical to ensure that claims are accurate, which results in clean claims and fewer denials.

Eye Codes

Medical billers understand the differences between E&M and current procedural terminology (CPT) codes, whereas the E&M codes should only be used when a visit to an ophthalmologist includes a medical element. This includes a patient history, physical exam, and a medical decision based on an assessment. CPT codes, and more specifically, those related to ophthalmological services and procedures, must be used when the visit is “vision” related. Eye codes include general and special ophthalmological services, procedures, contact lens services, spectacle services, and more complex codes that relate to prostheses. 

Coronis Health patient getting an eye exam Ophthalmology Medical Billing Services

E&M Codes

Medical billing codes for ophthalmology include a wide range of CPT codes that narrow down the specificity of a service or procedure, but E&M codes are related specifically to the medical component of a visit with an ophthalmologist. These codes range from 92202 to 99499 and are used for visits or services that relate to the evaluation and management of a patient. Medical billers understand that without an ocular indication, the E&M codes are appropriate to use on a claim. The ophthalmologist’s documentation determines the level of service that assigns the E&M code.

How to Use Ophthalmology Codes Correctly in Your Medical Billing Process

Medical billing for an ophthalmology facility is an elemental segment of creating a thriving and viable revenue cycle; accurate billing using the right codes protects the overall revenue health and growth of an ophthalmology facility. An increase in billing errors and claim denials or rejection can lead to a decrease in reimbursement and the potential of payor audits. Using the CPT and E&M codes correctly for an ophthalmology facility requires an exceptional understanding of the differences and restrictions of the codes.

Seasoned medical billers understand the nuances of billing for an ophthalmology facility, and the importance of using the two different sets of codes. Other healthcare specialties do not have the same intricate balance between the two types of codes. There is also a strong focus on an insurance payor’s specific rules that relate to ophthalmology, medical necessity requirements, or the elements of a specific exam. 

Because the diagnosis codes for eye-related conditions are limited, medical billers must understand how to apply each code to the wide range of CPT codes and when to apply E&M codes. Diagnosis codes are limited in their application to the eye codes; E&M codes are not as restricted but should only be used if a visit includes history, physical, or medical decision-making.

man auditing ophthalmology medical billing on laptop coronis health

Eye codes also include “frequency edits”, which relate to how many times a patient can use a specific service, such as an annual eye exam. The ophthalmology facility must check a  patient’s history of visits and the limitations of the code, as some services are limited to one annual visit. 

Tips for Ensuring Accurate and Timely Medical Billing With Ophthalmology Codes

Medical billing and coding for an ophthalmology facility is complex, but when these tips are followed, accurate and timely medical billing is attainable.

  • Always check the diagnosis codes – Remember that eye codes are restricted to what is considered medically necessary (codes vary by each payor). 
  • Use E&M codes only when a visit includes a “medical element” – Eye codes should only be used if the visit is only related to vision or a visual element. 
  • Check for frequency limitations – These limitations involve the frequency of visits within a period of time.
  • Documentation requirements vary by payor – Eye codes require specific types of documentation. Review the guidelines and rules for each payor. 
  • Out-of-network (OON) billing – While OON billing is acceptable, risks include an increase in claim denials, late payments, or the potential of fraud and abuse. The key to avoiding issues with an OON plan consist of upfront patient collection, transparency with patients regarding cost, and using the same charge amount on claims that you would apply to determine a patient payment. 
coronis health woman on a computer for page about medical billing services for ophthalmology

Following these simple steps will ensure that your facility is focusing on documentation and compliance, accurate and timely billing, and ultimately providing an optimal patient experience.

Common Mistakes to Avoid When Coding for Ophthalmology Medical Billing

Avoiding mistakes in medical billing results in a lower rate of claim denial, timely reimbursement, and a robust management of your revenue cycle. Mistakes do happen, but focus on these common mistakes to avoid with ophthalmology coding:

  • Missing or invalid modifiers – Modifiers indicate that a procedure or service has changed, but not to the point of needing to use a different code.
  • Expired global periods – This is a period of time when all services are included in one bundled payment. Global periods have an expiration date, so medical billers must understand how to apply different codes in this case, even if a patient receives treatment that is related to a procedure performed during the global period. 
  • Inaccurate or unsupported diagnosis codes – These codes must support the medical necessity, and claims can be denied if the codes are incorrect. Codes must be assigned at the highest level of specificity, including coding chronic conditions whenever applicable. 
  • Patient ineligibility at time of service – Insurance should be verified at every visit. Additionally, if ID numbers are not entered accurately, a claim will be denied. 
  • Procedure or service is considered experimental – Eligibility and benefits must be verified to ensure that specific services are included in a patient’s plan. One payor may consider a procedure medically necessary, while another will view it as experimental. Doing the work on the front end will save your facility denied claims and extra work. 

Questions about Coding for Ophthalmology Medical Billing? Contact Coronis Health Today!

The complexities of medical coding and billing for ophthalmology range from understanding how to document to applying different types of codes for a wide variety of services and procedures. The billing and coding teams at Coronis Health know how to navigate the intricacies of coding for an ophthalmology facility. If you have questions about how to optimize your coding and billing, contact Coronis Health today for a free financial checkup and see how you can maximize your revenue.

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