Submitting clean claims and getting them paid in a timely manner is what keeps your ophthalmology practice afloat. But anyone who’s involved in ophthalmology billing knows that it’s not exactly a walk in the park. Opportunities for missteps abound—missteps that will slow your revenue cycle to a crawl, and worse, land you in the crosshairs of auditors. Keep reading for five tips that will help you stay in compliance, and in the money.
5 Must-Know Ophthalmology Billing Tips
Correctly choose between eye codes and E/M codes.
Unlike other specialties, ophthalmologists have two sets of codes to choose from for ophthalmology billing. This adds flexibility to your billing, but also confusion. To choose the right code, take a look at your payer rules, the exam elements you performed, medical necessity requirements, and the reimbursement rates for the codes you’re considering. More specifically, consider these additional decision factors to help you choose the code that best reflects the care provided:
- Check your diagnosis code(s). Eye codes are more restrictive as to what diagnosis meets medical necessity, and the specific codes can vary by payer. E/M codes do not share those same restrictions.
- Use E/M codes for visits that have a medical element. If the exam is strictly visual and contains no medical elements, an eye code is the right choice.
- Check the patient’s history, because eye codes have frequency edits. For example, you’re limited to billing code 92014 once per 12-month period per patient. E/M codes don’t share those same frequency edits.
- Verify payer guidelines. While the documentation requirement for E/M codes is standardized over all payers, the required documentation for eye codes may vary.
- All things being equal (if you meet the required elemets for both an eye code and an E/M code), choose the code with the highest level of reimbursement.
Be careful with out-of-network billing.
Most providers end up billing out-of-network (without a payer contract) at some point. However, OON billing can open you up to risks including increased denials, late payments, and even violations of fraud and abuse laws (like the False Claims Act). If you do bill out of network, follow these best practices to stay in the clear:
- Be completely transparent with patients about your out-of-network status. Explain OON status both verbally to the patient and in writing as part of your practice’s financial policy.
- Do your best to estimate patient payments upfront to avoid balance billing. Surprise billing is on the radar of state and federal lawmakers.
- Never routinely waive patient co-pays or other out-of-pocket payments. This could be considered an incentive to refer, violating the Anti-Kickback Statute.
- Use the same charge amount on claims that you use to calculate patient payments.
Rethink your patient billing statements.
Medical billing statements are notoriously confusing, even for patients with high health and financial literacy. If you don’t make your statements clear, simple, and easy to read, your patients—even the ones who can pay with no problem—are likely to set it aside to “deal with later.” That means more days in A/R for you, and more frustration (and less patient satisfaction) from your patients. For billing statements that pay up, try these tips:
- Describe services in lay terms. Don’t use codes and medical jargon. Patients want to know exactly what they’re paying for.
- Use a clean layout, with large, sans-serif font and lots of white space. Omit any unnecessary verbiage.
- Include clear directions that explain why the patient owes what they owe (i.e. we have billed your insurance company, but there is a remaining amount due from you…”).
Get familiar with your payers.
Both commercial payers and Medicare have varying coverage determinations and ophthalmology billing guidelines. Even within Medicare, the individual MACs will differ as to how they want you to code a bill and what supporting documentation they want to see. To submit clean claims, you must know and follow each payers guidelines.
For example, Medicare requires that you bill bilateral claims by listing the procedure code once on the claim and appending modifier 50. Other payers want you to list the procedure code on one line with modifier LT, and then on the next line again with modifier RT. A great way to help your billers with this is to create a payer matrix or cheat sheet with your most commonly billed codes and how they differ between payers.
Bill accurately for diagnostic testing.
Ophthalmology billing for diagnostic tests is always under scrutiny from auditors, and violating the rules can easily land you in hot water. You need to pay attention to using the right modifiers, meeting medical necessity guidelines, and documenting clearly and completely. Here are some common problem areas:
- Visual Field Testing: This is part of the general ophthalmological service (92081-92083) so don’t report visual fielt testing separately with these codes—that’s considered upcoding.
- OCT may not be reported bilaterally. You may report only once on a claim, regardless of whether it was performed on one or both eyes.
- Fundus photography: Watch your frequency and make sure documentation supports medical necessity. For example, most payers will only reimburse for fundus photos one time per year for slowly evolving diseases, and twice per year for rapidly evolving diseases.
- IOL calculations: Know how to use modifier TC (technical component). Modifer TC is inherently bilateral. That means you can only report the technical component of an A-scan once, even if its done on both eyes. In contrast, the professional component is unilateral, because the provider typically performs the calculation separately on each eye prior to the corresponding surgery. That means you can bill the professional component and append modifier 50.