Billing for Ophthalmology and Optometry can be challenging if the practice does not take the initiative to gather all necessary information before the visit date. The first step toward providing the best possible care to patients is to understand their needs and establish clear, effective communication. Billers need detailed insurance information in order to submit clean claims and patients need to be aware of the benefits and limitations of their coverage. Knowledge is the key to successful billing.

Well-trained office staff will always ask the right questions in order to understand what type of eye care a patient need. For eye health issues, patients might have both medical and vision coverage. Office needs to confirm if it will be a yearly vision exam with refraction and/or contact lens fitting or will the visit be for a medical issue such as itchy or infected eyes, flashes or floaters, blurred vision, etc. One thing not to do is to assume that patient will know which insurance will be billed and what will be billed. Once the need is established, the next step is to explain to the patient the extent of insurance coverage for the visit and patient’s options for charges to be billed. A few extra minutes spent on the phone and on the day of the exam with patients will save hours later in following up with both insurance and patient for payments.

The following are some basic information that Ophthalmology and Optometry staff needs to know in order to maintain a well-managed practice.

Vision Plans: Typical vision insurance plans cover an annual eye exam, and prescription check for eyeglasses and/or contact lenses. They will also partially cover the cost of materials, such as frames, lenses, contact lenses, etc. Some plans will have these benefits every 24 months or longer, instead of yearly benefits. To avoid any surprise billing, the office must verify coverage before appointing patients. Vision plans, such as Blue Vision, Davis Vision, EyeMed, March Vision, Spectra, VSP, etc have different plans for patients to choose from; therefore, it is important not to assume type of coverage. Many Medicare advantage plans now have vision coverage as well. Tricare and Medicaid plan also might have vision coverage for members. The best policy is always to verify coverage before an appointment. Some vision insurances, such as VSP, might also offer limited medical coverage for patients with certain medical conditions, such as Diabetes.

Medical Plans: Medical plans mostly cover visits related to medical diagnosis and treatment. Patients coming to an eye doctor might automatically assume the visit will be billed to vision insurance, especially if the patient will be seeing an Optometrist. Vision insurances have little to no co-pays. They also do not have any co-insurance or deductible. Medical insurance might have higher co-pays, co-insurance, and deductible amounts. If the patient is making an appointment for a medical issue; the provider’s office needs to clearly explain to the patient which insurance will be billed and why. When possible, it is always a good idea to collect any due amount on the day of the visit with a clear explanation to the patient for the reason for the charges.

Medical and Vision Plans: What You Need to Know

• Verify patients’ benefits for both vision and medical plans. This way the practice, provider, and patient can make informed decisions.
• Some vision plans require prior authorization. It helps both provider and insurance to keep the service booked and confirmed for the specific provider for the given encounter date.
• Vision claims should be billed with eye visit codes 92002 or 92004, and 92012 or 92014.
• Medical visits billed to medical insurances have a higher reimbursement rate than vision insurances.
• Vision insurance covers limited services. Routine vision care is allowed once per year or every 24 months, depending on the plan. Material benefits are fixed to a certain dollar amount or percentage discount from the total.
• Medical plans most often will not have restrictions on the number of visits.
• Some medical insurance might not recognize Eye codes; in that case, E&M codes will have to be billed.
• Do not bill visits to medical and vision insurances on the same day.
• Chief complaint, findings and interpretations, and care plan have to be carefully documented in the exam.
• CMS can make changes to CPT and diagnosis codes and code descriptions during the year. Be sure to read all mail and emails from insurance companies to stay updated.

Farida Chowdhury, OCSR, MA, BS
Billing and Coding Specialist
MedBillingStrategies.com