Optometry Billing and Coding: Year in Review 2024
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Highlights
- In 2024, practices saw several optometry billing and coding changes that required new documentation and reporting.
- Among the major changes were CMS reimbursement rates and quality reporting standards.
- Also included were significant changes to CPT and ICD-10 codes for optometry.
- Pending legislation signals new changes ahead for 2025.
- Updating your technology can simplify the process of adapting to yearly changes.
2024 brought major 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 2025, review the changes and learn how to keep your practice efficient and ahead of the curve.
Key Medicare Fee Schedule Changes
The Centers for Medicare & Medicaid Services (CMS) introduced significant changes to optometry billing in 2024.
- Initial conversion factor decrease. The year began with a 3.4% decrease in Medicare’s conversion factor, dropping it to $32.74. Due to the CMS conversion factor changes, practices noticed smaller payments for the same services compared to previous years.
- Mid-year conversion factor increase: However, a mid-year adjustment brought some relief. The Consolidated Appropriations Act of 2024 increased the conversion factor to $33.29, effective March 9, 2024. This 2.93% update provided a partial offset to the initial decrease.
- Overall reimbursement reduction. Despite the mid-year adjustment, overall reimbursement rates still declined by 5.4% due to factors like sequestration adjustments.
- Estimated charges for optometrists. The total allowable charges for optometrists were reduced to $1.29 billion, a slight decrease in potential revenue.
ICD-10 Code Updates
2024 marked a significant shift in optometry billing and coding practices with the implementation of new ICD-10-CM H codes. These revised codes, specifically designed for eye and adnexa diseases, provide more precise diagnoses for conditions like sickle cell retinopathy, extraocular muscle entrapment, and foreign body sensation.
A total of 34 new codes were added to ICD-10-CM Chapter 7 to improve documentation for these conditions.
The increased specificity and complexity of the new codes presented challenges for optometrists, requiring careful attention to detail and accurate documentation.
Notable CPT Code Updates
In addition to the Medicare changes, the AMA rolled out updates to several CPT codes that optometrists frequently use. It also established new quality measure requirements that optometry billing teams needed to comply with.
New Codes and Changes
The most significant CPT code change for optometrists in 2024 was the modification of the E/M (Evaluation and Management) codes.
The time-based criteria for selecting these codes were removed. Instead, the focus shifted to medical decision-making and the complexity of the visit.
Other CPT code updates in 2024 included:
- Spanish language descriptors for medical procedures, supporting more inclusive care.
- A new suprachoroidal injection code, 65716, replaced Category III code 0465T to improve clarity and standardization.
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.
CMS has removed the routine dilated eye exam for age-related macular degeneration (AMD) for all patients, aligning with the latest guidelines. This change reduces unnecessary testing for some patients, streamlining care without compromising quality.
MIPS and Quality Reporting
If your practice participates in the Merit-Based Incentive Payment System (MIPS), these changes applied to you in 2024.
MIPS quality reporting changes included:
- Stable performance threshold. Although CMS proposed an increase, the threshold remained at 75 points, giving providers continuity in scoring expectations.
- Longer reporting period for interoperability. Providers had 180 days to meet data-sharing requirements, offering additional time to align with interoperability standards.
- Delayed adoption of electronic measures. Medicare Shared Savings Program participants received an extension before the mandatory adoption of electronic Clinical Quality Measures, allowing more preparation time.
Telehealth Billing Changes
Place of Service Updates
Starting 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
- Modifier 95 is no longer required for telehealth claims.
- Medicare will stop covering telehealth services on December 31, 2024.
Compliance and Billing Practices
The National Correct Coding Initiative (NCCI) and legislative bodies also made changes to billing regulations last year.
Here’s a brief summary.
NCCI Edit Considerations
NCCI raised the bar on billing standards this past year 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.
Looking Ahead to 2025
Several changes in optometric billing and coding are expected to affect practice management in the coming year.
Here’s what optometrists need to know.
- G2211 add-on code implementation. In 2025, Medicare will allow practitioners to add the G2211 code for visit complexity when billing specific office and outpatient evaluation and management (E/M) services. The change will help create new reimbursement opportunities for providers.
- Electronic quality measure requirements. New electronic requirements are changing how practices collect data and report standards. For example, practices using multiple EHR systems must consolidate data to meet the 75% completeness standard for accurate reporting.
- Ongoing legislation. Two legislative initiatives were introduced in 2023 that could affect optometry in 2025 and beyond
- H.R. 2474, the Strengthening Medicare for Patients and Providers Act, aims to stabilize Medicare payment rates. This bill was introduced in 2023 but would not take effect until 2026.
- H.R. 3674, the Providing Relief and Stability for Medicare Patients Act of 2023, would temporarily increase the payment rate under Medicare for certain office-based services that involve high-priced equipment. It will apply to services provided in 2024 and 2025.
- New legislation. A new bipartisan bill (H.R. 10073, the Medicare Patient Access and Practice Stabilization Act of 2024) would:
- Eliminate the proposed 2.8% Medicare payment cut for 2025
- Provide a 4.7% positive payment update
If these bills pass, optometry practices could benefit from more stable Medicare reimbursement rates, which would reduce sudden revenue fluctuations and ease financial strain on billing.
Best Practices for 2025 and Beyond: How Technology Can Help
Stay ahead in 2025 with an integrated optometry practice management platform with tools that make coding and billing easier. RevolutionEHR’s automated optometric billing software equips your practice with tools that simplify guideline adherence, improve patient connections, and keep billing straightforward so you can spend less time on paperwork.
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.
- Automate coding for accurate billing. RevolutionEHR’s auto-coding feature supports consistent, compliant coding by automatically linking diagnostic codes with specific exam findings. This reduces manual input and errors, ensuring each claim is accurate and maximizes reimbursement.
- Automate claim submission and tracking. RevBilling automatically handles claim submissions and gives real-time updates on claim status. This feature eliminates the time-consuming steps involved in manual claims management, helping you monitor the entire process with ease.
- Reduce claim denials and payment delays. RevBilling minimizes the chances of denials or payment delays by auto-checking claims for errors before submission, reducing rework and accelerating reimbursement. Auto-checks are especially useful for practices that handle high volumes of claims and need to maximize payment efficiency.
- Ensure compliance and coding accuracy. RevBilling integrates with RevolutionEHR’s reporting and ICD-10 auto-updates, so your coding is always current with the latest regulations. This seamless integration reduces errors related to outdated codes, ensuring your practice remains compliant and reducing the risk of audits.
- Improve cash flow with faster processing. RevBilling’s automation speeds up claim approvals and payment processing, allowing for a more predictable and steady cash flow. With this reliable revenue cycle management, optometrists can focus on practice growth without worrying about cash flow disruptions.
- Enhance transparency with detailed reports. RevolutionEHR’s reporting tools work with RevBilling to generate in-depth financial and coding reports, allowing you to monitor revenue metrics, identify trends, and make informed decisions to optimize your practice’s financial 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 2025
Take charge of your practice’s billing and coding in 2025 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.