Ophthalmology and Optometry Coding Alert

Here’s how to save your practice money, time, and a whole lot of frustration.

If denials are up and revenue is down, it might be time to reevaluate your billing and collection procedures. Periodically brushing up on ophthalmology billing best practices helps minimize mistakes and discrepancies in coding, which can incur serious financial losses and adversely affect your collections.

Avert these disastrous consequences by checking out this list of the top 10 mistakes to avoid, as well as expert advice that can help you drive the best returns and optimize your billing processes.

Mistake 1: Forgetting To Verify Vision and Medical Insurance Benefits

Patient insurance eligibility verification is one of the easiest ways to maintain clean claims, but verification is often the most neglected step in the billing process. Eligibility verification ensures the insurance data is correct and helps determine the amount a patient may owe (e.g., co-pays, co-insurance, and deductibles). Providing patients with more accurate cost estimates can significantly boost patient satisfaction, increase capture of patients’ out-of-pocket costs at the time of service, and save you from future claim denials.

Many patients have both a vision plan and medical insurance and while it might seem obvious which plan you need to bill based on the patient’s chief complaint and diagnosis, occasionally, it’s more complicated. Circumvent potential problems by being proactive and verifying the patient’s vision and medical plans before the office visit.

Mistake 2: Missing Diagnoses or Maximum Specificity

Since it’s very important that you do not list narrative descriptions on your claims, your diagnosis codes must clearly tell the story of why the patient was seen. “The claim form allows for 12 different diagnosis codes, but oftentimes not all 12 are utilized,” says Carleen Parker, representative for Medicare carrier NGS in Minnesota. “You should always code your diagnoses to the highest level of specificity,” she adds. Pay attention to instructions in ICD-10 that indicate the number of digits required in the code series you are using; more digits likely add more specificity.

Mistake 3: Using Modifiers Incorrectly

Realize that there are codes you can’t bill together on the same day except under certain circumstances. For example, many offices bill optical coherence tomography (OCT) and scanning laser polarimetry with variable corneal compensation (GDx) (CPT^® codes 92133, 92134) and fundus photography (92250) on the same visit.

While the National Correct Coding Initiative (NCCI) edits allow you to use a modifier to unbundle OCT/GDx and fundus photography, your chart notes must support it. Using a separate diagnosis is not sufficient to support unbundling this edit. When unbundling is appropriate be careful to use the modifier correctly, or it may result in a rejection or denial. Depending on local policies, if both tests are necessary use modifier 59 (Distinct procedural service) or XU (Unusual non-overlapping service …) depending on payer preference.

Mistake 4: Using Special Characters, Including Periods

Be sure to eliminate all special characters, such as hyphens, periods, parentheses, or dollar signs, from the claim form. This includes the use of decimal points in ICD-10 codes, so be sure to scrub all decimals from your diagnosis codes before entering them on the claim form.

Mistake 5: Not Consistently Checking for Pertinent Updates

To ensure you are coding your eye care claims correctly, you must remain diligent with Local Coverage Determinations (LCD) and Medicare Administrative Contractors (MAC) in your area and sign up to receive payer listserv updates.

Mistake 6: Failing To Double-Check A/R, Fee Schedules

You should review the accounts receivables (A/R) aging monthly and pay close attention to the “over 90-day” column. Instead of just rebilling the claims, follow up by phone and build a rapport with the claim reps. Collect all patient copays, refraction fees, and the 20 percent on surgery cases when no secondary insurance exists, and update the practice’s fee schedule regularly.

“Sometimes a practice hasn’t updated their base fees for five years, so they’re leaving money on the table,” says Patricia Morris, MBA, COE, an ophthalmology consultant based in New York. “The insurance company is not going to tell you they pay out more than you are billing. They will continue to pay you your rate while paying other providers 10 percent to 15 percent more for the same code.”

Mistake 7: Lack of Regular Follow-Ups on Denied Claims

No eye care practice likes seeing those denied claims in their inbox. While the process of tracking down why the claim was denied is cumbersome and not what the billing staff wants to do, “you’ve got to work your denials,” Morris notes. The longer you wait to determine what went wrong, the lower your chances of collecting the maximum amount (or any) from the insurance payer.

The good news is, on average, two-thirds of denials are recoverable, and nearly 90 percent are avoidable. Routine follow-up on denied claims can help your practice maintain an optimal revenue flow by resolving outstanding balances quickly and efficiently, in turn improving collections.

Mistake 8: Failing To Review Reasons for Denials and Adjustments

To prevent denials, eye care practices must perform internal audits and educate themselves on the common factors that cause them. A majority of claim denials are due to administrative errors, such as the procedure code being inconsistent with the modifier used, or the required modifier missing for the decision process (adjudication). Once you correct the errors, you can resubmit the claim to the payer.

Take the time to call and question denials. Many times, you can correct and refile the claim instead of writing it off completely. You should also share your denial rate, common reasons for denials, and how to avoid them with your coding staff. Hopefully, educating them will reduce the number of future errors.

Mistake 9: Letting Patients Leave Before Collecting Money Owed

A great way to increase your practice cash flow is collecting at the time of service rather than sending bills after the fact. This means collecting copayments, deductibles, and charges for non-covered services like refractions before the patients leave your office. This simplifies it for the patient, helps maintain a healthy revenue stream for the practice, and reduces administrative costs and efforts in sending statements. A trifecta of good news!

Additionally, when you have to send patient statements, consider sending them long before the due date to reduce accounts receivable delays and late payments.

Mistake 10: Not Obtaining an ABN for Non-Covered Services

If you suspect that the procedure or service you will provide to the patient may not be covered, obtain a signed waiver from the patient. This documents the patient’s understanding and acceptance of financial responsibility Have the patient sign the waiver before you provide the procedure or service. This makes them obliged to pay after the appointment, as needed.