Top 9 Optometry Coding Audit Triggers

auditing optometry coding


  • Optometry coding audit triggers are billing practices that alert insurers to potential misuse of CPT codes and inaccurate documentation procedures. 
  • Optometry practices should be aware of the most common audit triggers and take steps to avoid them to reduce the risk of an audit. 
  • Common audit triggers for eye care practices include misuse of modifiers 25 and 59, excessive use of high-level E/M codes, and inadequate documentation for certain procedures. 
  • Training staff, staying updated on CPT code usage, and using an optometry EHR with auto-coding and built-in documentation features can minimize audits and improve billing at your practice. 

Insurance audits can be challenging aspects of managing an optometry practice. They can consume time and money and may affect your clinic’s reputation. Errors in coding and documentation can lead to optometry coding audit triggers, unwanted scrutiny, and operational disruptions.

For instance, insurers often view common optometry billing errors, such as overapplying high-level E/M codes or accidentally misusing modifier 25, as red flags. Without the right documentation to support their use, you could face hefty penalties or sanctions.

Knowing the top coding audit triggers and how to avoid them with optometry billing software can reduce your risk of audits and ensure smooth billing practices.

1. Excessive Use of High-Level E/M Codes

When optometrists frequently bill using high-level E/M codes like 99205 and 99215, it can lead to increased scrutiny from auditors. This practice, known as upcoding, means billing for more complex evaluations than those performed. If your practice consistently uses these level 5 codes without clear, detailed documentation justifying the high level of care, you might face audits and potential penalties.

2. Incorrect Usage of Comprehensive Ophthalmological Exam Codes

Another common optometry audit trigger is the inappropriate use of CPT codes 92004 or 92014 for comprehensive ophthalmological exams. Auditors target practices that bill comprehensive exams without justifiable medical necessity. If your documentation doesn’t support the need for these extensive assessments, use intermediate codes like 92002 or 92012 that match the level of service provided. Otherwise, you may face a medical necessity audit from insurers.

3. Conducting Unnecessary Diagnostic Tests

Unnecessary diagnostic tests such as fundus photos or OCTs can trigger audits because they often do not influence clinical decision-making. If you bill these tests without a clear connection to symptoms or a specific diagnosis, auditors may see this as a sign of overbilling. This pattern indicates that the practice uses tests routinely, not based on individual medical needs, which can lead to increased reviews by insurance providers.

optometry exam

4. Improper Application of Modifier 59 for Unbundling Procedures

Improperly applying modifier 59 to unbundle procedures that are not distinct or independent can lead to audit triggers. For example, if you use modifier 59 to bill fundus photos and OCTs as separate entities when they are part of a single diagnostic session, auditors might view it as an attempt to inflate billing. This misuse suggests an intentional separation of services that should be billed together, prompting closer inspection and potential penalties.

5. Misuse of Modifier 25 for Non-Separate E/M Services

Modifier 25 is used to indicate that a significant, separately identifiable evaluation and management (E/M) service was provided along with another procedure on the same day. Misusing this modifier can make an audit more likely. For example, if you attach modifier 25 to a claim for a minor, routine adjustment and bill it as a significant separate service, auditors might see this as an attempt to inflate billing and start an investigation.

6. Mischaracterizing Routine Vision Exams as Medical Visits

When routine vision exams are mischaracterized as medical visits, it can lead to coding audits. For example, your practice documents blurred vision as a medical reason for a visit, but the issue was resolved with a new glasses prescription. This suggests the visit was routine, not medical. Billing routine vision exams as medical visits may prompt insurers to review these claims for potential overcharging, increasing the risk of audits and fines.

7. Inadequate Documentation for Vision Therapy and Contact Lens Exams

Inadequate documentation for vision therapy codes like 97110, 97116, and 97533, and contact lens exams (CPT code 92310) can lead to coding audits. If the records for these services don’t meet the detailed requirements set by vision plans, such as specific measurements or detailed treatment justifications, insurers may question the validity of the claims. A lack of thorough documentation can result in heightened audit activity and potential penalties, as it suggests non-compliance with billing standards.

8. Abnormal Billing Patterns Compared to Industry Standards

You may face coding audits if you have abnormal billing patterns that differ from industry standards. When billing habits, such as the frequency of certain procedures or the use of specific codes, don’t follow standard usage patterns among optometry practices, it alerts insurers to potential misuse. Examples can include:

  • An unusually high number of certain high-cost procedures
  • Frequent billing of complex codes not common among similar practices
  • Consistent use of modifiers that alter reimbursement rates

These deviations suggest potential inaccuracies or intentional overbilling, prompting closer inspection.

9. Billing Issues Related to Non-Provided or Inadequately Performed Services

Billing for services that were not provided or were delivered by unqualified or excluded employees is a serious issue that can lead to audits. For example, claiming reimbursement for a complex procedure that never occurred or a service performed by someone not certified to do so will raise suspicions.

Insurers might look into these claims to verify compliance with healthcare regulations and prevent fraudulent billing, which could result in severe penalties and damage to the practice’s reputation.

trying on glasses

Tips for Avoiding Audit Triggers at Your Practice

Audit triggers can be a serious issue for your optometry practice. They can result in time-consuming, invasive investigations and stalled or lost revenue from delayed or rejected claims.

Here are a few helpful tips on how to avoid optometry audits when billing:

  • Understand coding guidelines. Familiarize your team with the current coding standards and requirements in optometric care. Stay updated with the American Medical Association’s (AMA) annual CPT code changes and regularly review the Centers for Medicare & Medicaid Services (CMS) site for the latest guidance on new use requirements.
  • Maintain accurate documentation. Keep detailed records that justify each billed service. Ensure entries outline the patient’s condition and the specifics of the service provided, distinguishing them from routine care. Use optometry EHR software like RevolutionEHR, which offers drop-down diagnosis and SOAP note templates. This simplifies documentation and improves record quality, reducing coding errors and boosting efficiency.
  • Regular staff training. Provide ongoing training for your billing and clinical staff to keep them updated on the latest coding practices and insurance regulations. Include real-life scenarios and changes in payer policies in the training to reduce the likelihood of errors.
  • Perform your own audits. Regularly conduct internal billing audits to identify any deviations or inaccuracies before they attract external scrutiny. These audits can help correct improper billing practices early and ensure every claim complies with health insurance standards.
  • Use automated practice management software. Use RevolutionEHR’s practice management software like RevolutionEHR, which has features like built-in CPT codes, an automatic coding engine, and automated billing and insurance verification. The system suggests and corrects codes based on the services provided, flags potential issues before claims are submitted, and streamlines your billing cycle.

Join the Revolution Today with a Free Demo from RevolutionEHR

Optometry coding compliance is essential for the sustainability and profitability of your practice. With the right tools and practices in place, you can maintain billing accuracy and improve operational efficiency.

Join the Revolution today with a free demo from RevolutionEHR. Explore our all-in-one platform, which provides tools for accurate billing, seamless documentation, and error management, allowing you to focus on delivering exceptional patient care.

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