Answers to Your Top Billing and Coding Questions

By Rachael Wruble, OD, FAAO

I get asked a fair share of questions pertaining to billing and coding, but there are a handful that come up regularly. Following are some of the more common billing and coding topics.

TO CREDENTIAL OR NOT

The biggest question I hear from new graduates is, “What do I do next? Do I start credentialing on an insurance panel?” If you’re joining a clinic, they may have someone who helps you credential. I help my doctors credential, but if one of them starts talking about partnership, then I want them to credential themselves, work with my staff, learn about the insurance companies, figure out the largest health care plan providers in the community, and compare the rates in the area. Having potential partners credential themselves helps them understand the process and the paperwork that is involved. You can negotiate rates for vision and medical plans with insurance companies. Every state and every carrier is different.

MEDICARE & MEDICAID

Many doctors want to know if they should accept Medicare. Well, Medicare represents about 60 million patients in our country right now,¹ so it’s probably not a bad idea. Medicaid is another one I get asked about a lot, and some states are switching from straight Medicaid to managed care contracts, which has been difficult because the contracted rate may not be at 100%; it may be significantly lower. If your state hasn’t yet made the switch from straight Medicaid to managed care Medicaid, I encourage you to work with your state association and state optometric society on those rates, because they can be negotiated with the managed care plans. Then you’ll want to look at all of the commercial plans to see what’s big in your area and find out what the local hospitals and employers have. Blue Cross, United Healthcare, Cigna, Humana, and Aetna may have routine eye exams that pay a little higher than the actual vision plan. It’s confusing, but important to know what’s what. Make a cheat sheet if necessary. Having a cheat sheet for the staff and doctors helps them understand the billing side of insurance.

SETTING EXAM FEES

The easiest way to figure out your exam fees is by consulting the Medicare allowables, which are set by the Centers for Medicare & Medicaid Services.² Note that these do change, so I create a task for myself on one of my administration days once a year to go through and look at these allowables and see where we are with all of our most common diagnoses. My EHR generates a report so I can check to see if I need to raise or lower my fees. You don’t want to set your fees lower than what Medicare pays because you’ll be leaving money on the table, so make sure you’re setting your fees at or above Medicare levels.

IMPROPER CODING

Using the wrong code or undercoding an exam is oftentimes the result of physician inexperience. If you code an eye exam as new and it results in a denial, that usually means the patient doesn’t meet the new candidate guidelines, and that you will have to refile, which takes many weeks. Thus, it’s important to try to bill and code properly the first time.

BILLING ERRORS

The three most common billing mistakes involve: 1) mixing up routine versus medical visits, 2) misused and unused modifiers, and 3) submitting a claim before you’re credentialed.

Routine Versus Medical

I had a new staff member who was part of my insurance team get their wires crossed, and all of a sudden we’re billing 99214 for presbyopia when 99214 is for a medical exam. Presbyopia is not a medical diagnosis, so this billing error resulted in a ton of denials.

Misused and Unused Modifiers

Using modifiers incorrectly or not using them at all is another common billing mistake. If you’re providing postoperative care, use modifier 55. However, use modifier 54 (the surgeon’s modifier) and your claim will be denied.

Submitting a Claim Before You’re Credentialed

A new doctor may receive a welcome letter congratulating them, but it doesn’t mean they’re fully credentialed. They may still have required training to complete with an insurance company, so if they submit a claim, they’re not going to get paid for any of them as in-network. Make sure you’re fully credentialed.

UNDERBILLING

You won’t get penalized for underbilling, but you won’t get paid what you should be paid for the services that you are providing.

the more you know ...

Credentialing can seem daunting with all the paperwork, but take it one step at a time. Medicare, Medicaid, and commercial payers may continuously change policies. Keep an active membership with your state association to be aware of updates. It is important for eye care providers and their staff to be aware of different aspects of testing, billing, and coding guidelines in order to both file correct claims with insurers the first time and also to understand their practice habits, which may result in receiving reduced fees for their services.

• 1. CMS releases latest enrollment figures for Medicare, Medicaid, and children’s health insurance program (CHIP). CMS.gov. December 21, 2021. www.cms.gov/newsroom/news-alert/cms-releases-latest-enrollment-figures-medicare-medicaid-and-childrens-health-insurance-program-chip#:~:text=As%20of%20October%202021%2C%20the%20total%20Medicare%20enrollment%20is%2063%2C964%2C675. Accessed August 21, 2022.
• 2. Physician fee schedule look-up tool. CMS.gov. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup. Accessed August 24, 2022.

Glaucoma Coding and Billing Considerations

By Thomas Cheezum, OD, CPC, and Walter O. Whitley, OD, MBA, FAAO

When it comes to billing and coding for glaucoma, there’s a lot we can talk about, but this article addresses some of the most common questions pertaining to this topic. If you have a question not addressed here, let us know.

WHAT’S THE FREQUENCY?

Some of the more common questions we get is how often OCT can be performed, how often visual fields can be performed, whether multiple tests can be done together, and how often we should be seeing our patients with glaucoma.

When it comes to frequency guidelines (eg, testing, visits, etc.), it’s all about what information is necessary to diagnose, treat, and manage your patient while following the standard of care for the level of disease severity. Great resources are available, including the American Optometric Association Optometric Clinical Practice Guidelines and the American Academy of Ophthalmology Preferred Practice Patterns.^1,2

For a patient with borderline or controlled mild to moderate glaucoma, once a year OCT (92133) is covered, but uncontrolled glaucoma may warrant OCT performed at least two times a year, based on medical necessity. For visual fields (92083), once a year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled, and three times per year for rapidly progressing disease.

Remember that anytime you order a test, documentation is key. Include what test you need, why you need the test, what information it gives you (including comparative analysis to previous tests), and next steps in management.

Another consideration when ordering tests is that Medicare applies a multiple procedure payment reduction (MPPR) to the practice expense (PE) payment of select procedures and services. Full payment is made for the procedure with the highest PE payment, and for subsequent procedures to the same patient on the same day, full payment is made for work and malpractice and 50% payment is made for the PE for procedures submitted on either professional or institutional claims. You could perform visual fields, OCT, and a full dilating exam every single time, but you will get reimbursed 100% for the first test, and then only 50% for the second test. Unless it’s medically necessary, it’s not clinically efficient to do both tests on the same day. Additionally, we typically see patients two to three times per year, so you could space the special testing out throughout the year, which also raises your ticket price per visit.

WATCH IT NOW

Walt Whitley, OD, MBA, FAAO, and Will To, OD, ABOC, discuss the benefits of networking with fellow optometrists and sharing tips about billing and coding at the 2022 MOD Live meeting. Watch here.

STAGING PATIENTS

Glaucoma staging is important because it not only determines how we code and bill our patients’ conditions, but it also helps us determine how much pressure lowering we want to do.^1,2

For example, a patient with mild glaucoma has optic nerve abnormalities, but they’re not going to have visual field defects unless it’s detected on frequency doubling or short wavelength automated perimetry test. In this case, we would want about a 20% to 30% reduction in IOP.^4,5 A patient with moderate glaucoma will have visual field defects in either superior or inferior hemifield outside of the central 5˚. Those are patients in whom we want about a 35% decrease in IOP. If it’s affecting both hemifields or if it’s within the central 5˚, then that patient has advanced glaucoma and we’ll want a target pressure of below 18 mm Hg and/or target low teens to reduce visual field loss and progression.⁵

You don’t want to do OCT on a patient with advanced glaucoma because of the limited information it provides due to the floor effect. (Also, most insurances won’t reimburse for it.) An adjustment to the stimulus size or a 10-2 threshold visual field test will provide more reliable information for detecting and monitoring progression.

OTHER CODING CONSIDERATIONS

• For ICD-10, if both eyes are at the same stage in the disease, then it’s important to use a bilateral code.
• Be as specific as possible when coding (ie, include stage, laterality, etc.).
• If each eye is at different levels of severity, then we want to code the more severe eye first.
• Use “indeterminate” when a patient hasn’t had a visual field or OCT done, but you suspect they have glaucoma and it’s unspecified. (Don’t use “unspecified”—billing people don’t like that.)
• Once again, make sure you have an order for each test.

FOLLOW THE RULES

Remember, proper documentation is key, along with orders for each test. Use available resources to guide your treatment and management protocols, which will help ensure proper coding and following the standard of care.