Top 5 Optometry Billing and Coding Errors: Prevention Guide

^{Updated Feb 10, 2026.}

Your optometry practice’s revenue cycle depends on clean claims. Small billing and coding mistakes can trigger denials, delay payment, and create hours of rework for your team. Over time, those issues can increase A/R, frustrate staff, and raise the risk of payer audits.

In this article, we break down the most common optometry billing and coding mistakes and how to prevent them. The goal is simple: help your team submit cleaner claims, get paid faster, and stay consistent—no matter which payer you’re working with.

How Billing and Coding Errors Hurt Practices

Billing and coding errors slow payments, create additional rework, increase A/R aging, and increase audit risk. CMS’ most recent improper payment reporting shows that traditional Medicare still sees billions in payments that don’t meet program requirements each year. In FY 2025, CMS estimated the Medicare fee-for-service improper payment rate at 6.55%, or $28.83 billion.

The takeaway for optometry teams is practical: The fastest way to reduce denials is to tighten the “claim basics” that payers look for: accurate codes, correct dates, and documentation that supports medical necessity and specificity.

5 Common Mistakes

Success in optometry billing requires attention to detail and understanding of specific coding requirements. Let's examine the five most common errors that lead to claim denials and how to avoid them.

1. Medical vs. Routine Examination Confusion

Medical and routine eye examinations serve different purposes, but many optometrists struggle with the distinction. A medical exam must focus solely on tests necessary for diagnosis and treatment of a specific condition. 

The key difference lies in medical necessity — an exam should be billed as medical only if the primary diagnosis is medical in nature.

Example Scenario: Patient presents with complaints of flashes and floaters. While it's tempting to perform a complete routine exam with refraction, the medical necessity only supports tests directly related to the retinal evaluation. Billing for additional routine tests could trigger a denial.

Documentation Example

Medical Exam

• Chief Complaint: Sudden onset of flashes and floaters in right eye
• Tests Performed: Dilated fundus examination, OCT scanning
• Diagnosis: Posterior vitreous detachment
• Billing: Medical insurance with relevant medical necessity documentation

2. Duplicate Claims Submission

Duplicate claims are one of the most frequent — and preventable — reasons for denial. They can happen for several reasons:

• Multiple submissions of claims with matching billed amounts
• Identical procedure codes submitted for the same date of service
• Resubmission of previously processed and paid claims

Quick rule: If a correction is needed, submit a correction (replacement/adjustment) rather than sending a new, identical claim. Medicare processing systems automatically identify exact duplicates and may auto-deny them.

Example Scenario: A practice submits a claim for a comprehensive eye exam (CPT 92014) on March 1st. Not seeing payment by March 20th, they resubmit the claim. Meanwhile, the original claim was being processed, resulting in both claims being flagged as duplicates and denied.

Proper Tracking Example

• Claim #12345
• Service Date: 3/1/2025
• Procedure: 92014
• Initial Submission: 3/1/2025
• Status Check: 3/20/2025 - In process
• Follow-up: Phone verification with payer
• Resolution: Payment expected by 4/1/2025

3. ICD-10 Code Specificity Issues

ICD-10-CM codes are updated on a defined schedule, and payers expect the highest level of specificity available (often including laterality, type, and stage). When you’re unsure, use the CDC/CMS ICD-10-CM release files and the FY 2026 Official Guidelines for Coding and Reporting as your references—not guesswork or old cheat sheets.

• Document what the code needs: laterality (OD/OS/OU), condition type/subtype, severity/stage when applicable, and the clinical findings that support medical necessity.
• Confirm operational readiness: the code exists in your PM/EHR picklists and clearinghouse, and your payer is adjudicating it as expected before you scale usage.

Coding Example

• Incorrect: H25.9 (Unspecified age-related cataract)
• Correct: H25.811 (Right eye specific cataract)
• Supporting Documentation: Location, type, severity
• Additional Findings: Visual acuity, symptoms

4. S-Codes and CPT Code Misuse

The distinction between S-codes and CPT codes creates confusion for many practices, particularly when billing different insurance types. Commercial insurers may require specific S-codes for certain services. For instance, they might only cover glasses when claims use the correct S-codes for polycarbonate and single prescription lenses.

Example Scenario: A patient needs new glasses with polycarbonate lenses. Medicare won't cover materials, but the patient's secondary commercial insurance will — if coded correctly.

Coding Example

Medicare (Won't Cover):

• 92015 - Refraction
• 92340 - Fitting of spectacles

Commercial Insurance (Will Cover):

• S0580 - Polycarbonate lens
• S0581 - Standard progressive lens
• V2100 - Sphere, single vision
• V2200 - Sphere bifocal

5. EHR System Limitations

Working with outdated Electronic Health Record systems can significantly impact coding and billing accuracy. Common issues include:

• System glitches that record incorrect examination codes
• Unalterable data fields that create documentation inconsistencies
• Inability to keep up with Medicare and Medicaid requirements
• Limited adaptation to private insurance coding changes
• Inadequate support for increasing optometric care demands

Example Scenario: A practice's outdated EHR automatically defaults to routine exam codes even for medical visits. Staff must manually override each code, increasing error risk and processing time.

System Comparison Example

Outdated EHR:

• Manual code entry required
• No real-time verification
• Limited insurance rules
• Basic error checking

Modern EHR:

• Automatic code suggestion
• Real-time claim verification
• Updated payer rules
• Advanced error prevention

A Clean-Claim SOP (no yearly code updates required)

If you want fewer denials without turning your team into coding specialists, standardize a short process that catches the common problems before submission:

1. Pre-visit insurance check: confirm plan type and whether the visit should be billed as medical vs routine.
2. Encounter documentation guardrails: require laterality and key clinical findings for diagnoses that commonly deny when unspecified.
3. Claim “duplicate prevention” step: check claim status before resubmitting; correct vs rebill when appropriate.
4. Pre-submission validation: run error checks for missing data, mismatched codes, and common payer rejections.
5. Weekly denial huddle: review the top 3 denial reasons and assign one workflow fix (not just resubmissions).

This approach keeps the article evergreen and gives office managers a system they can actually run—without competing with annual Medicare/CPT update content.

Prevent Billing and Coding Errors with RevBilling 

Modern technology offers solutions to many common billing challenges. RevolutionEHR's integrated system provides specific tools and features designed to prevent coding errors before they happen. 

Smart Coding That Works for You

• Auto-coding engine. Our intelligent system suggests appropriate codes based on your documented exam findings, reducing errors and saving valuable time.
• CPT code triggers. Set up custom triggers that automatically populate billing codes based on your typical exam workflow and documentation patterns.
• Real-time validation. Catch potential coding issues before submission with built-in compliance checks that help prevent costly claim denials.

Streamlined Billing Management

• One-click claim submission. Submit claims directly through RevClear, our integrated clearinghouse that achieves a 98.06% payer acceptance rate.
• Automated payment posting. Save hours of manual data entry with automatic payment reconciliation and precise account balance tracking.
• Comprehensive reporting. Generate detailed financial reports to track revenue, identify trends, and make data-driven decisions about your practice.

Built-In Audit Protection

• Complete audit trails. Every billing action is automatically documented, providing peace of mind and strong audit defense.
• Compliance monitoring. Stay current with coding guidelines through automatic updates and built-in compliance checks.
• Documentation support. Our templates help ensure your clinical documentation properly supports your billing codes.

Schedule a demo today to see why thousands of optometrists simplify coding and billing, reduce denials, and protect their financial health with RevolutionEHR. 

FAQs

How do I determine if an exam should be billed as medical or routine? Look at the primary reason for the visit. If the patient presents with medical symptoms or conditions requiring diagnosis and treatment, bill as medical. If it's for general vision assessment and updating prescriptions, bill as routine.

What's the best way to prevent duplicate claim submissions? Implement a tracking system for all submitted claims and use automated verification tools. Wait for the standard processing time (typically 30 days) before following up on unpaid claims.

What documentation is required for medical necessity? Include detailed symptoms, diagnosis codes, test results, and treatment plans that clearly support why each procedure was necessary for the patient's condition.

How can I improve my claim acceptance rate?

• Verify insurance coverage before appointments
• Document medical necessity thoroughly
• Use specific diagnosis codes
• Submit claims within timely filing deadlines
• Implement automated coding validation

How often should I update my EHR system? Stay current with quarterly updates at minimum. This ensures compliance with new coding requirements and takes advantage of the latest features for improved billing accuracy.