Ophthalmology and Optometry Coding Alert

Question: Should we report exactly the same group of codes to all payers, or can we submit the payable CPT codes to each payer as long as we're sure we don't miss anything or underbill?


Washington, D.C., Subscriber
Answer: Because covered services vary according to payer--some payers only recognize the E/M codes for medical eye problems, and the eye codes (92002-92014) for optometric services--you may often find it difficult to manage which insurers accept which codes.

You might assume that it is easier to report only the covered services to each payer to eliminate the number of adjustments you will have to make, but this may actually cause you more trouble.
 
There's also the risk of ineligible coverage since patients may change insurers without notifying your practice. And, if the patient has primary and secondary insurance, you may need to receive a denial from the primary insurer before the secondary insurer will cover  the service.

Important: Submitting charges for the services you provide regardless of payment may help in attaining future coverage. If your physician provides a high volume of medically necessary, but non-covered services, you may be able to negotiate for coverage when revising contractual agreements.
 
To do this successfully, you may need to pool the data of services provided appropriately to the beneficiaries but denied by the insurer.

So, although it may be tempting to eliminate some of the perceived work, be sure of what is in your best interest before you change your operational process.

In the case of E/M versus eye codes, you may also try to educate payers by pointing out that the eye codes are not purely for optometric or refractive services and are seen as medical in CPT and by Medicare. In many cases, simply submitting a copy of a claim to Medicare and proof of their coverage and payment can help to expand the CPT coverage of the eye codes by your payer.