Optometry Billing FAQs

Applied Medical Systems


FAQs from Optometry practices across the country answered by Applied Medical System’s expert Optometry Billing Specialists.

Q: Can I bill for retinal photography even if there is no medical diagnosis?

A: Retinal photography or fundus photo billing (CPT 92250) can be tricky. Although optometrists understand the value of routine screening with a retinal camera, most payers will not pay unless there is a documented medical condition that was notated in the record before the test was run. Running a screening and finding retinopathy is still considered a screening.

The best way to handle this is to think of retinal screening and retinal diagnostic imaging as two different services. Upon check-in, the front desk staff should explain to the patient the value of a retinal screening even if there is no history of retinopathy. It is useful to have a form that briefly explains this. The patient can then choose to opt-in to the screening and pay the private payer price (since there is no insurance price) or opt-out and pay nothing. When charging for a screening, use a code other than 92250 (make one up for your system) so that you can prove to any auditors that you are not providing screening services at diagnostic prices.

Q: Is refraction considered included in a comprehensive exam?

A: Good question. Although refraction is considered a very important part of any eye exam from a provider’s point of view, it is NOT included in the CPT description of a comprehensive exam. Refractions are billed with their own CPT code, 92015, and this code is not covered by Medicare or most other medical insurance payers. Front desk staff should make Medicare patients aware of this upfront and collect accordingly.

Q: So can I do refraction on my Medicare patients and just not charge them for it?

A: You sure can- as long as you don’t charge ANY of your patients for refraction. Medicare is very strict about having a single set of billing practices applied to all insurance companies. It is recommended to collect a refraction fee on all patients for whom this service is performed and not paid by the insurance company.

Q: If something needs to be submitted via paper claim vs through a clearinghouse, does that fall under your scope?

A. Yes! Our job is to get those claims to the payer in the appropriate form so that they pay. We prefer to file electronically as much as possible and will request you enroll in EDI for all available payers. However, we know some payers will only take paper claims either as primary or as secondary payers.

Q: If a claim is denied for invalid diagnosis, but it is, in fact, a valid diagnosis, what is the process?

A: We’ll research and resubmit. There’s always a valid diagnosis to be found! If a payer says the diagnosis does not support a procedure, we’ll do our best to appeal and/or recode. However, sometimes these claims will end up patient responsibility (if an ABN/release was signed) or a write-off (if not.)

Q: Do you add/delete/correct modifiers, etc?  For example, we do punctal plugs but aren’t sure we’re coding them right.

A: Yes. That is a good example of a state and payer-specific code. We have internal resources that keep track of the favored modifier combination for each common code and payer. We try to update the provider as to payer preferences so the correct modifiers can be used going forward.

Q: If a claim is denied because we accidentally coded it as a new patient instead of established, do you correct that and re-submit, or do we have to fix it and resubmit?

A: We will correct this and resubmit.  92004s will automatically be recoded to 92014s, etc. If it’s a 99xxx code, we may query the provider unless you tell us upfront to automatically re-code to the established patient parallel code.

Q: Do you submit to secondary and tertiary payers?

A: We do. If your system is set to send them electronically, that’s great, but otherwise, we will print and send them from here.

Q: If a claim is denied because of extra diagnosis codes on the CMS form that are irrelevant to the medical code, do you fix that and resubmit, or do we?

A: We would fix that. We have certified coders on board who are comfortable editing the coding on a claim (within the bounds of proper coding and compliance) to the payers’ tastes. As always, if we aren’t sure what the provider is trying to say to the payer, we’ll query them.

Q: Do you send patient statements out regularly? If a balance gets moved to the patient because of deductible etc, how soon is a statement generated?

A: That is up to the provider and the software system. Some systems allow for weekly statement batches and we prefer that, too. If there’s no way to do that, we’ll generate your statement file monthly. We recommend using a statement service as it’s often less expensive than print-fold-stuffing in house. No matter how statements go out, we offer our 800 number for them so your patients can call our dedicated optometry line to have all their billing inquiries answered.

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