Maximizing reimbursement and minimizing denials in eye care practices

Why Clean Claims Matter in Ophthalmology

Clean claims submission is crucial for ophthalmology practices due to complex procedures, high-value claims, and specialty-specific coding requirements. A single denied retinal procedure can cost $3,000-$5,000 in lost revenue, plus $25-$50 in administrative rework costs.

Ophthalmology billing challenges:

• Complex bilateral procedures requiring specific modifiers
• High-value claims attracting payer scrutiny
• Intricate prior authorization requirements
• Medicare and commercial payer policy variations
• Global period considerations for surgical procedures

Bottom line: Practices with robust clean claims processes achieve 2-3% denial rates versus industry averages of 5-10%.

Pre-Submission Checklist

Patient Demographics and Insurance Verification

✓ Patient Information Accuracy

• Full legal name matches insurance card exactly
• Date of birth verified (MM/DD/YYYY format)
• Current address and contact information
• Social Security Number when required
• Gender designation matches insurance records

✓ Insurance Verification

• Primary and secondary insurance active on service date
• Coverage verification for planned procedures
• Copay, deductible, and coinsurance amounts confirmed
• In-network provider status verified
• Claims submission address confirmed

✓ Eligibility and Benefits

• Vision vs. medical coverage determined
• Annual limits and remaining benefits checked
• Coordination of benefits rules applied

Documentation Requirements

✓ Provider Documentation

• Physician signature on all forms
• Date and time of service documented
• Chief complaint and history of present illness
• Examination findings support diagnosis
• Treatment plan and medical necessity established

✓ Ophthalmology-Specific Documentation

• Visual acuity measurements (distance and near)
• Intraocular pressure readings when applicable
• Fundus examination findings (optic nerve, macula, vessels)
• Anterior segment examination details
• Diagnostic test results attached when relevant

Coding Accuracy Checklist

ICD-10 Diagnosis Coding

✓ Primary Diagnosis Selection

• Most specific code available
• Laterality specified (right eye, left eye, bilateral)
• Acute vs. chronic conditions identified
• Combination codes used appropriately

✓ Supporting Diagnoses

• Relevant conditions affecting treatment included
• Comorbidities impacting medical necessity listed
• Proper sequencing per ICD-10 guidelines

✓ Key Ophthalmology ICD-10 Ranges

• H00-H59: Diseases of the eye and adnexa
• H25-H28: Disorders of lens
• H30-H36: Disorders of choroid and retina
• H40-H42: Glaucoma

CPT Procedure Coding

✓ Procedure Code Selection

• Most specific CPT code chosen
• Bilateral procedures properly coded
• Multiple procedures follow CCI guidelines
• Global period considerations noted

✓ Key CPT Ranges

• 65091-68899: Eye and ocular adnexa procedures
• 92002-92499: Ophthalmological services
• 67028-67043: Retinal procedures
• 66830-66999: Lens procedures

✓ E/M Code Selection

• Appropriate level based on complexity
• New vs. established patient status verified
• Eye codes (92002-92014) vs. E/M codes selected appropriately

Modifier Usage

✓ Essential Modifiers

• -RT/-LT: Right/left side
• -50: Bilateral procedure
• -22: Increased procedural services
• -25: Significant, separately identifiable E/M service
• -57: Decision for surgery
• -78/-79: Return to OR (related/unrelated)

✓ Modifier Application

• Appropriate modifier selected
• Multiple modifiers sequenced correctly
• Supporting documentation justifies use

Billing Details

Prior Authorization

✓ Authorization Requirements

• Prior auth obtained when required
• Authorization number included on claim
• Covers specific procedure and diagnosis
• Service date within approved timeframe

✓ Common Procedures Requiring Auth

• Retinal injections (anti-VEGF drugs)
• Complex cataract surgeries
• Glaucoma procedures
• Retinal surgeries
• High-frequency diagnostic testing

Place of Service Codes

✓ Correct POS Codes

• 11: Office
• 22: On-campus outpatient hospital
• 24: Ambulatory surgical center

Special Considerations

Surgical Procedures

✓ Cataract Surgery

• IOL type documented (standard vs. premium)
• Surgical technique specified
• Global period services identified

✓ Retinal Procedures

• Injection location specified
• Drug dosage and NDC numbers included
• Repeat injection timing justified

Diagnostic Testing

✓ Visual Field Testing

• Medical necessity documented
• Frequency limitations observed
• Technical quality acceptable

✓ OCT Testing

• Appropriate diagnosis supports testing
• Frequency guidelines followed
• Image quality documented

Quality Assurance

Pre-Submission Review

✓ Claims Scrubbing

• Electronic scrubbing software utilized
• CCI edits reviewed
• LCD compliance verified

✓ Internal Audit

• Random claim sampling (5% monthly)
• Coding accuracy verified
• Documentation completeness confirmed

Common Pitfalls to Avoid

Critical Mistakes:

• Missing laterality indicators
• Unbundling procedures incorrectly
• Inadequate medical necessity documentation
• Incorrect bilateral procedure modifiers
• Missing prior authorizations
• Claims submitted beyond timely filing limits

Documentation Issues:

• Unsigned provider notes
• Missing visual acuity measurements
• Copy-paste documentation without customization
• Insufficient examination findings

Key Performance Indicators

Target Metrics:

• Clean claims rate: >95%
• First-pass resolution: >90%
• Days in A/R: <30 days
• Denial rate: <5%
• Collection rate: >98%

PRO TIP:

Implementing this checklist can significantly reduce claim denials and improve cash flow. Clean claims submission requires systematic processes, ongoing staff education, and attention to ophthalmology-specific requirements.

Success strategies:

• Create standardized workflows
• Conduct monthly denial pattern reviews
• Provide regular coding update training
• Maintain clear clinical-billing communication
• Stay current with regulatory changes

The investment in proper billing processes pays dividends through faster reimbursement, reduced administrative costs, and improved practice efficiency.

Need expert RCM support? Contact us to discuss how we can help maximize your revenue.