Wiki How to correctly bill for ophthalmology provider

[tatumroe]

We have an opthalmologist who states that 90% of her visits are medical and not routine. The patients often come in with a complaint such as blurry vision or seeing spots, some have diabetes and she's performing an exam on them but when we bill the medical plans some deny stating they are not the contracted payer and then we also get denials from the vision plan. The vision plans also do not pay very much. How do we know when to bill to the medical plan vs the vision plan?

 

[saddie2k]

Most ophthalmologists ARE medical visits. Yearly diabetic exams are absolutely medical. On those, make sure the diabetes dx code is primary on the claim. Are you using E/M or the eye codes? There are lots of reasons why you may be getting denials. Are you billing refractive icd's on medical claims? Systemic icd's on eye codes? Are the providers par with the plan your billing? Too many scenarios. Medical plan for medical problems, vision plan for refractive/routine.