Optometry Billing & Coding: 2025 Year in Review + 2026 Updates

^{Updated Feb 10, 2026.}

Last year brought several updates to optometry billing and coding, changing how practices handle claims, reimbursements, and compliance. Medicare and AMA's new codes and guidelines have redefined industry standards that affect optometry billing.

Meeting legal obligations isn't just about avoiding penalties; it also maximizes your optometry reimbursement rates. With the right strategies and tools, you can streamline billing processes and capture every dollar your practice has earned. 

If you want to improve your optometry billing and coding in 2026, review the changes below.

Medicare Physician Fee Schedule Updates for 2026

For CY 2026, CMS finalized two conversion factors:

• $33.57 for qualifying APM participants
• $33.40 for non-qualifying APM participants

Because reimbursement is ultimately driven by the conversion factor multiplied by Relative Value Units (RVUs) (and then adjusted by locality and policy rules), small shifts can still materially affect expected payment, even when your CPT coding habits don’t change.

When forecasting, validate your current year fee schedule and locality assumptions before updating patient estimates or internal fee schedules.

^{Source: CMS CY 2026 Medicare Physician Fee Schedule Final Rule Fact Sheet.}

2026 Checklist

ICD-10 Code Updates: What to Verify Before Coding

ICD-10-CM is updated regularly, and payers may adopt changes on slightly different timelines.

For FY 2026, use the CDC’s official ICD-10-CM release files to confirm new, revised, and deleted diagnosis codes, along with the effective dates (including the annual October 1 update and any mid-year update).

Before you apply a newly published diagnosis code in production, confirm it’s present in your clearinghouse, PM/EHR, and payer adjudication logic.

Notable CPT Code Updates

CPT updates take effect each January, and while most annual changes don’t materially alter day-to-day optometry workflows, it’s worth scanning the code set every year for the items that can affect documentation, claim edits, and payer coverage. For 2026, the biggest ophthalmology-specific CPT updates highlighted in reputable coding summaries center on dark adaptation testing.

Dark Adaptation: 2026 Changes to Know

• CPT 92284 (revised descriptor): The 2026 CPT code set updates the description for 92284 to clarify how the service is reported for dark adaptation testing, including interpretation and report. If your practice performs diagnostic dark adaptation, review the updated descriptor and confirm your documentation supports medical necessity and includes an interpretation/report.
• CPT 92288 (new code): CPT 92288 was established to report screening dark-adaptation measurement, with interpretation and report. Because “screening” services can be treated differently across payers, confirm coverage and payment policy before you build this into routine workflows.

Practice tip: When a CPT change involves a diagnostic vs. screening distinction, take a minute to align your templates so documentation clearly reflects the clinical intent, medical necessity (when applicable), and that an interpretation and report are completed. This small step can prevent denials and minimize back-and-forth with payers.

New Codes and Changes

For office and outpatient E/M services, code selection is based on medical decision making (MDM) or total time (per the modern E/M guidelines). That means your documentation should clearly support either (1) the elements of MDM you relied on, or (2) the total time you spent on the date of the encounter, consistent with the guideline definition of time.

In 2026, the operational win is the same: build templates and provider habits that consistently capture the support you’ll need if a claim is reviewed.

Quality Measure Updates

Optometrists now have clearer guidance on connecting patients with community resources and addressing overall well-being beyond eye care. There is also a renewed emphasis on screening for intraocular pressure to detect glaucoma early, promoting long-term eye health.

Quality reporting requirements can change year to year based on the MIPS/QPP measure set and measure specifications. If you’re aligning documentation or workflows to a quality measure, verify the current year’s measure specifications and reporting rules in QPP before you treat any measure as “required” or “retired.”

MIPS/QPP Reminders for the 2026 Performance Year

If you participate in Traditional MIPS, use QPP’s current-year requirements as your source of truth for reporting rules, scoring, and deadlines. For the 2026 performance year, CMS maintained a 75-point performance threshold (confirm requirements and any program updates directly in QPP before you finalize your reporting plan).

Build your internal checklist early (especially if you’re changing vendors, workflows, or measure selections).

Telehealth Billing Changes

Place of Service Updates

As of January 1, 2024, practices must now use new place of service codes for telehealth:

• POS 02 for telehealth provided outside the patient’s home (facility rate).
• POS 10 for telehealth provided in the patient’s home (non-facility rate).

Documentation Changes

Telehealth coding details can vary by payer and setting. For Medicare, pay close attention to the place of service (POS) guidance (commonly POS 02 for telehealth provided other than in the patient’s home and POS 10 for telehealth provided in the patient’s home, when applicable) and follow CMS telehealth billing guidance for any modifier requirements that apply to your specific service type.

Telehealth coverage and billing rules have changed repeatedly over the last few years, including extensions and policy updates. Instead of relying on a single “end date,” treat telehealth as a verify-before-billing category: confirm current Medicare telehealth policy and your payer’s requirements before submitting claims, especially when you’re using telehealth for services that can be billed either in-person or remotely.

NCCI Changes

The National Correct Coding Initiative (NCCI) and legislative bodies made changes to billing regulations in recent years. 

NCCI raised the bar on billing standards in 2024 for optometry practices, including:

• A focus on procedure-to-procedure (PTP) edits to block incompatible services from being billed together.
• Limiting how often specific services can appear on claims using medically unlikely edits (MUEs) to keep billing within approved boundaries.

These changes also tighten rules on diagnostic tests, so when billing tests like fundus photography alongside OCT, follow the updated guidelines to prevent denials.

2026 notice: NCCI edits can change quarterly, and those updates can materially affect imaging combinations.
For example, AAO/AAOE noted CMS agreement to eliminate certain NCCI procedure-to-procedure edits involving CPT 92137 and specific angiography codes in a quarterly update window. If your practice bills advanced imaging, check each quarterly NCCI update and validate any previously denied code pairs before you assume a bundling rule is permanent.

What to Watch in 2026

To keep claims clean in 2026, focus less on predictions and more on the update categories that reliably drive denials, underpayments, or compliance risk:

• Medicare PFS changes: Confirm the current year conversion factor, locality adjustments, and any policy changes that affect how services are valued or paid.
• ICD-10-CM updates: Validate FY 2026 diagnosis code changes and effective dates using the CDC release files, then confirm payer adoption in your own workflow.
• Telehealth rules: Verify current CMS guidance and payer-specific requirements before billing, because coverage and billing details can shift.
• MIPS/QPP requirements: Confirm your current year reporting requirements and measure specifications early enough to adjust documentation and data capture.
• NCCI quarterly edits: Review each quarterly update for imaging and procedure pair edits that can change bundling and payment behavior.

If you only do one thing: Set a quarterly reminder to review CMS/QPP updates and NCCI edits, then update your internal cheat sheets and templates immediately before small changes in claim volume make them expensive.

Streamline Billing with RevolutionEHR and RevBilling

RevBilling, integrated within RevolutionEHR, takes the complexity out of optometry billing by automating claims processing and ensuring accuracy from start to finish. 

Here’s how RevolutionEHR and RevBilling simplify coding and billing.

• Auto-code more consistently. Link diagnoses to exam findings to cut manual entry and reduce coding errors.
• Submit and track claims faster. Send claims through RevBilling and see claim status updates in real time.
• Catch errors before you bill. Pre-check claims to reduce denials, rework, and payment delays.
• Stay current and compliant. Keep ICD-10 and coding workflows aligned with updates and reporting to lower audit risk.
• Get paid more predictably. Speed up claim processing to support steadier cash flow.
• See what’s working. Use reports to spot trends, track revenue metrics, and improve billing performance.

RevBilling’s robust automation, compliance features, and real-time tracking make it an invaluable tool for optometry practices. It offers a streamlined approach to billing that saves time, reduces errors, and increases revenue consistency.

Master Optometry Billing and Coding in 2026

Take charge of your practice’s billing and coding in 2026 with RevolutionEHR. Stay compliant, minimize claim denials, and free up more time for patient care. Use tools like RevAspire for accurate audits and reporting features that track key metrics to help you maximize your reimbursements.  

Discover how RevolutionEHR can transform your workflow. Book a demo today and experience the difference.