Ophthalmology and Optometry Coding Alert

Question: Our practice has a few claims that have missing or incorrect information. I’m not sure what to do with these claims. Should we just put them through anyway and keep our fingers crossed?

New Jersey Subscriber

Answer: Trying to put through an incomplete or incorrect claim will probably result in an immediate denial, so don’t waste your time doing so. Instead, put these claims on hold or suspend them, then do some homework on these claims soon. You’ll be more likely to find the information you need to submit a clean claim. 

Claims can be held or suspended for a variety of reasons. They may have a missing diagnosis code, a code that is no longer valid, or be missing important information. Luckily, most billing software allows you to hold or suspend claims that have such errors. After you suspend the claim in question, check the patient’s medical record. The supporting medical information to assign correct codes should be there, or you may have to check with the clinician if there is missing information in the chart. If so, let your provider know what information you should be seeing on the chart.

You should also check with payer policies and local carrier determinations (LCDs) to research the need for additional documentation, diagnoses, or modifier usage. The Medicare physician fee schedule database is also a great resource to check on supervision requirements and whether or not a service can be billed with an assistant surgeon, etc. Also check the CCI edits to determine if the problem has to do with a bundling issue.

If the missing information is patient related, such as policy number, address of the payer, address confirmation, or referral, you should contact the patient and get the missing information.