Optometry Billing and Coding: Don’t Make These Costly Errors


  • Coding and billing errors can cost optometry providers thousands in insurance claim denials each year.
  • Common errors often occur due to improper diagnosis codes, duplicate claims, and incorrect S and CPT codes.
  • Using RevolutionEHR’s automated, integrated software minimizes coding and billing errors and maximizes profits for optometrists.

The timely payment of insurance claims is essential for optometric practices to maintain their revenue flow. Billing and coding mistakes can lead to claim denials and interrupted cash flow.

All-in-one integrated optometry EHR software from RevolutionEHR can minimize costly coding and billing errors to improve claims reimbursement and increase revenue.

The Cost of Billing and Coding Errors for Providers

When coding and billing errors occur, optometry practices can lose revenue due to inaccurate claims and unnecessary payments. According to 2021 Medicare Fee-for-Service Supplemental Improper Payment Data, the projected estimate of improper payments for optometrists was $46,101,404. These erroneous payments represent an error rate of 6.4% among optometry practices.

When optometrists are able to correct coding and billing issues with automated solutions, they add more money to their practice revenue. For reference, a primary care physician can bring in $124,435 in preventative services and $86,082 in coordination services when they follow proper coding practices.

Common Optometry Billing and Coding Errors

The following billing and coding errors often occur when optometrists and their staff use outdated or non-integrated EHR and practice management systems. These mistakes can lead to costly claims denials, making it vital for optometrists to avoid them.

1. Lack of Understanding Between Routine and Medical Examinations

Medical and routine eye examinations may seem similar, but the difference is that a medical exam must only include tests necessary to diagnose a patient and treat them. The exam should be billed as medical if a primary diagnosis is medical. However, many optometrists perform the same tests as routine eye exams for every patient.

The additional tests for a routine exam can result in an inaccurate increase of the code level for a visit. An insurer may deny a claim if they don’t deem a procedure or diagnosis medically necessary.

2. Submission of Duplicate Claims

Insurance companies will deny a claim if it is a duplicate of a previously submitted claim. For example, denials can occur when duplicate claims have matching billed amounts, procedure codes, or types of services.

In other instances, insurers already processed and paid the original claims. Duplicate claims often result when staff use outdated programs or manual methods to create and submit them.

claim denied

3. Unspecified ICD-10 Optometric Diagnosis Codes

The Centers for Medicare and Medicaid Services (CMS) and other insurers require the highest level of specificity under the ICD-10 coding system for coding claims. For instance, age-related nuclear cataracts have four codes. One states the diagnosed condition, and three codes identify the affected eyes.

An unspecified code in a submitted claim can indicate the optometrist failed to record which eye has the diagnosed condition. Consequently, the payer may question the medical necessity to process a valid claim.

4. Improper Use of S-Codes and CPT Codes

Optometry practices may confuse coding between S-codes and CPT codes, leading to mistakes among billing commercial insurance companies, Medicare, and Medicaid. Some commercial insurers might only pay when you submit a claim with the correct S-code. For instance, they may pay for glasses, but only if you use the S-codes for polycarbonate and single prescription lenses.

5. Outdated EHR

Working with an outdated EHR can affect your coding and billing practices. A defect in an EHR, such as a glitch that inaccurately records the wrong codes for eye examinations, can result in resubmitting corrected claims to insurers. Inconsistencies between data fields, such as when there are unalterable choices, can cause errors.

You may need to upgrade your EHR if your patients use Medicare or Medicaid. Additionally, private insurance routinely implements coding changes, and an outdated EHR may not meet the increased demand for optometric care.

How RevolutionEHR Streamlines Optometry Project Management

RevolutionEHR offers an inclusive, cloud-based solution for optometrists who want to streamline their coding and billing process and ensure timely payments with no issues from insurers. Optometry practices can benefit from the software’s ease of auto-coding and patient management.

Efficient Auto-Coding in the Patient’s Records

You can use personalized CPT triggers when billing and coding to optimize your billing and coding accuracy. RevolutionEHR allows for auto-coding when you meet with a patient, saving you time.

Our software assesses the patient’s medical history documentation and recommends the proper coding under evaluation and medical coding guidelines. It offers a list of appropriate codes for any eye exam when you review the patient’s charts.

For example, if you diagnose a patient with a refractive eye issue, it automatically codes the condition for you. The same coding module allows you to assign billable items to the appropriate insurance company and the patient. An automatic claim or invoice is generated based on these assignments.

Searchable Procedure and Diagnosis Codes

The platform lets you search for procedure, diagnostic, and service codes, eliminating the need to memorize them. You can also create a list of codes to make billing appointments easier by dragging and dropping them into a list.

Audit for Better Practice Management

Staff members can use the software’s accounting and billing features to submit valid claims to insurers. Accounting reports can show the revenue data from patients and procedure codes. These reports allow you to see if you input the correct CPT and S-codes in the patients’ invoices when you file with the insurance firms.

You can run financial reports by doctor or location if you have multiple offices to see how each one stacks up over specific timeframes for accurate billing. When submitting and reviewing claims, these reports can help you identify locations that need improvement.

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Prevent Costly Coding Errors with RevolutionEHR

RevolutionEHR is an all-in-one optometric EHR system that uses automated features to prevent costly coding errors. With RevolutionEHR, you gain the freedom to focus on other elements of your practice and improve patient care rather than worrying about coding and insurance.

Request a demo today to see how RevolutionEHR can revolutionize your optometry practice and streamline billing and coding for you and your staff.

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