The Top 10 Coding & Billing Errors of Optometry

Coding and billing is a hot topic for any practice and it has gained prominence in the last couple of years as awareness for proper billing and coding has increased. Doctors are becoming more aware about the benefits of proper billing and the pitfalls of ignoring this activity. Different practices have different tactics or methods to carry out the coding and billing activity and some of them turn out to be pretty creative. Similarly, practices have a lot of complaints about the same questioning the rejection or denial of a claim which ultimately leads to loss of profitability.

Following are the Optometry coding and billing errors that affect reimbursement:-

A duplicate claim is submitted-
If a submitted claim is an exact duplicate of a previous claim which was submitted, they will be denied on the grounds of being duplicate. This could happen because the claim might have been previously processed but it was not paid for some reason. Hence, to get the payment, the claim is refiled and it is considered a duplicate.
Billing for non-covered services-
Optometrists need to be careful about billing for the correct services. In a case where an excluded Medicare service like fitting and changing of eyeglasses or contact lenses despite no injury to the eye, it cannot be charged.
Medical necessity not established-
If the payer does not see the procedure or diagnosis as a medical necessity, then the claim can be denied.
Incorrect bundling of services-
This shows a lack of awareness of NCCI which governs the appropriateness of the tests being administered on the same date.
Ineligible beneficiary-
A claim which is submitted for the beneficiary who may not have the Medicare eligibility. Reason for the ineligibility could vary from Medicare number being invalid to the beneficiary not being eligible to receive this benefit.
Submission of payment to incorrect carrier-
If the claim is submitted to an incorrect payer the claim gets denied. For instance, one needs to be careful about the fact that if medical eye care services have been provided then the medical claim has to be submitted to the medical carrier.
Medicare turns out to be a secondary payer-
By the way of co-ordination of benefits; another payer might provide care for a Medicare patient. Hence be thorough with your knowledge of the payers.
Incorrect diagnosis-
When a primary listed diagnosis is not covered then the services can be denied for the procedures that have been performed.
Ambiguity in modifier-
The modifier is necessary to complete the claim, in a scenario where the modifier is missing, incomplete or invalid, the claim gets denied.
Ambiguity in provider number-
If the item numbers 24K and 33 are filled out incorrectly or the UPIN is incorrect or incomplete, it results in a denial of the claim.

Coding and billing are seemingly complex however keeping a tab on current and published policies which are easily available will ensure a high degree of success within the practice. Avoiding these top errors can take the optometry revenue cycle management and move towards greater profitability.

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