Ophthalmology and Optometry Coding Alert

When submitting a claim for an ophthalmic test, the record must include any photos, scans, or other hard copies as proof that the test or tests were performed. In addition, the documentation should contain:

• An order for the test with medical rationale
• The date of the test
• The reliability of the test (e.g., patient cooperation)
• The test findings
• A diagnosis, if possible
• The impact on treatment and prognosis
• Signature of the physician.

Why Might Your Claim Be Denied?

• There are several errors that can torpedo your claim. Some of the most common include:
• Testing being done for noncovered indications or lacking medical necessity.
• Not following insurance frequency guidelines. Rules vary by local carriers, so be sure to seek guidance from your local carriers.
• Inappropriate bundling of services. Always check the National Correct Coding Initiative (NCCI) edits to make sure that Medicare (and carriers that follow Medicare rules) will allow two codes to be reported separately.
• The use of invalid or inappropriate modifiers.
• Incomplete reports, especially if the CPT^® descriptor of the diagnostic test includes the phrase “with interpretation and report.”