10 Tips for Optimizing Your Coding and Billing

With vision care plan fees for various services growing stagnant (literally, for the past several decades),¹ more and more optometry practices are transitioning towards providing medical eye care for their patients. This trend can be financially beneficial because fees for medical care are significantly higher, and many patients in need of such services require more frequent visits, which further contributes to a higher gross income per year, per patient. In order to be paid appropriately for providing medical eye care, however, it is crucial that you become proficient in proper billing and coding. If you do not code and bill properly for your services, your practice could lose thousands of dollars per year in potential income.

Education is the key to avoiding loss of income. Below, I suggest 10 main ways to help your practice code and bill patient visits properly to ensure that you are appropriately compensated for your services.

TIPS FOR BEST PRACTICES

No. 1: Require Staff Education Courses

Oftentimes, a practice’s training program for coding and billing consists of simply having staff teach the new hires. Although this is theoretically a less expensive method, it can create a serious problem if the staff conducting the training has developed incorrect billing habits, which are then passed down to the next generation of billers.

This problem can be addressed by requiring staff to participate in annual billing and coding education provided by experts, which may include courses offered at annual state or national meetings, online courses and webinars, and/or written materials.

No. 2: Purchase New Code Books Annually

You must update your materials annually. Considering the fact that there are hundreds of CPT and ICD-10 code changes annually, using outdated or eliminated codes may result in denied claims.^2,3

No. 3: Learn How to Use the ICD-10 CM Code Book

One of the main reasons a payment may be denied is due to incorrect use of ICD-10 codes. Because the ICD-10 coding system became mandatory for use in 2015, the most important rule for selecting the appropriate code or codes has been to use the code or codes with the highest degree of “specificity.”

As such, many claims are denied because the practice submitted “unspecified” ICD-10 codes. With rare exceptions, these unspecified codes are no longer accepted by insurers. Often, practices fail to code with sufficient specificity because the billing staff simply does not know how to use the ICD-10-CM code book. There are several different instructions in this book, which guide you to use additional codes in addition to the main code that a biller may have chosen, or to list the codes in a certain order.

For example, when a patient with type 2 diabetes is seen, the ICD-10-CM code book instructs the provider to use certain additional codes for the medications used to control the patient’s disease, in addition to the code that may be used to describe any diabetic retinopathy.

No. 4: Understand Medicare Guidelines

Local Coverage Determinations are written by the regional Medicare carriers, such as Palmetto GBA or Novitas Solutions, and National Coverage Determinations are written by the Centers for Medicare & Medicaid Services (CMS). Although these guidelines are specific to Medicare claims, many commercial insurers also follow them. These documents provide a wealth of information, and every practice that provides medical procedures and specialized tests should become familiar with them, as they detail exactly what is required for documentation, testing frequency, and accepted diagnosis codes in order to be paid for these services. These resources (see Official Coding Guidelines) are readily available online at the CMS website or the appropriate regional carrier websites.

No. 5: Know How to Use the Correct Coding Initiative

The National Correct Coding Initiative (NCCI) provides information on which tests may or may not be performed on the same date of service. These guidelines are updated quarterly. Can you conduct a visual field test and retinal photography on the same date? The NCCI edits have the answer. Can you bill for retina photos and extended ophthalmoscopy on the same date? Again, the NCCI edits will be able to tell you, so be sure to check them to appropriately bill for diagnostic testing.

No. 6: Do Not Let Your EHR System Choose the Codes

Unless you have the knowledge to verify the electronic health record (EHR)-selected CPT and ICD-10 codes, allowing the EHR system to select the coding will most likely result in downcoding of the CPT codes for your visits and/or incomplete ICD-10 coding. Such errors can result in denial of payment and loss of income.

No. 7: Join Online Groups for Coding Education

There are several optometry-specific coding groups on social media platforms, such as Facebook. The members of these groups are a wealth of information and can answer questions and provide valuable guides to other members.

In my opinion, one of the best (and most active) Facebook groups you can join for this purpose is Billing, Coding and Tech Questions for Optometry. No question is considered too simple, and there are several certified coders in this group who can provide accurate answers to the questions asked. Whenever you join a new group or forum on social media, it is important to verify the credentials of the individuals whose coding and billing advice you are seeking.

No. 8: Update the Fee Schedule Annually

Although medical eye care fee increases may be minimal, it is important that your fee schedule be at least equal to the highest level of reimbursement you receive from any insurance carrier. With your practice’s expenses increasing, every dollar of income lost hurts your practice financially.

No. 9: Resubmit Denied Claims

If an insurer denies a payment for a claim, it is critical that your billing staff determine the reason for the denial, correct the issue, and resubmit the claim for payment. As a rule of thumb, if your denial rate is higher than 5%, then something is going wrong in your billing department, and you need to correct this larger, systemic issue through education. Also, be sure that denied claims are being reprocessed. You do not want to be the practice owner who discovers $30,000 worth of old denied claims hidden in a drawer. One way to determine whether denied claims are being properly refiled is to follow the dating on your accounts receivable. If you see a significant amount in your accounts receivable that are older than 90 days, you may have a problem.

No. 10: Hold Insurers Accountable

Several major medical insurers have begun to institute practices that make it more difficult for providers to be paid properly. Some are automatically downcoding E/M CPT codes for no apparent reason. Others are independently changing how the 920x4 ophthalmology codes may be used (ie, only when filing a claim for routine, nonmedical care, despite their CPT definitions stating that such codes are specifically for “medical examination” of the eye).⁴ This results in improperly denied claims, which must be recoded and resubmitted.

Frankly, these policies are abusive towards providers and require the unnecessary refiling or appealing of claims, which wastes valuable staff and clinician time. When you encounter these unjustified actions, be sure to appeal them to the carrier. If they do not respond, you can report them to your state insurance commission.

KNOW YOUR WORTH

When providing medical eye care, it is important to ensure you are being paid as much as you are owed for the valuable services you provide. If your practice follows the above billing and coding tips, you will find that you have fewer claims denied for payment, and you will be more knowledgeable in situations where you must appeal a denied claim.