Ophthalmology and Optometry Coding Alert

When someone outside of your office does your billing, it is to your practices benefit to try to get hold of some EOBs every now and then. This is especially true if there are no ophthalmology coding experts in the billing office, says Lori Butler, physician billing manager for the Vanderbilt Department of Ophthalmology and Visual Services in Nashville, TN.

Were a university medical center setting, and we dont do our own billing, she says. We make sure its coded correctly, and that its in compliance. But then it goes to another department, which files the claims. And to make things even more confusing, the payments come into a third department. So we never get to track whats going on, says Butler.

As the billing manager for the 15-ophthalmologist, 12-resident group, Butler does interact with the central billing office on a regular basis. Theres no one over there who knows about ophthalmology, she says. I find out by accident that things have been written off, things that shouldnt have been written off.

For example, the billing office was routinely writing off fundus photography (92250) because Medicare was denying the claims. When I found out about this, I appealed, Butler relates. I said, Youre paying for angiography (92235), so why wouldnt you pay for 92250? The EOBs always gave the reason for the denial as the place of service. Finally, Butler tracked down someone at the local Medicare carrier who agreed that this made no sense, and told Butler that if she could produce one EOB which showed Medicare had paid for fundus photography, the carrier would start paying again. We did, and they did, says Butler. And we resubmitted all the denied fundus photography claims, and got paid for them, too. The point, says Butler, is that you have to be a pest with insurance. When it comes to managed care, she adds, you just cant give up. But to pursue these appeals, you have to know a little bit about ophthalmology.

The lack of ophthalmology expertise in centralized insurance departments and outside billing firms can be a problem when it comes to contract negotiation as well, says Butler. When we go to contract meetings, the ophthalmologists get slaughtered, she says. Its very important to pay attention to routine eye care -- if its going to be carved out, what company is getting that part of the contract. Sometimes, its just a matter of a lack of communication. Recently, many rejections started coming in for routine eye care under one plan, says Butler. Nobody had informed the ophthalmologists that a different company had the carve-out for vision. Thats because many non-ophthalmology billers dont understand the dual nature of vision and medical coverage, a situation which is unique to ophthalmology.