Coding and Billing

Effective Billing and Coding Can Generate Otherwise Lost Dollars

By Eric Botts, OD

How much money are you leaving on the table due to inefficient billing and coding?  Plug a gaping revenue hole with proven strategies.

If you don’t view your optometric practice as a business, then now is the time to re-think your position. You are in the business of providing the best care for your patients. You pay your plumber, accountant, computer tech and others for their expertise and service. Your patients and their medical and vision insurance plans pay you for your expertise and service. Unfortunately, the days of all cash-pay patients are long gone and we are now required to play the insurance game to get paid for our services. Unlike your plumber who shows up, fixes the problem and presents you a bill for his services, our situation is not so easy.
Receiving full reimbursement for our services should be a priority for all optometric practices regardless of your mode of practice. All optometrists provide care for their patients and most of us accept assignments for medical and vision insurance plans. Here is where our world gets turned upside down as we try to wade our way through the tidal wave of credentialing, benefit verification, claim submission, claim denial, and hopefully, reimbursement. If you feel like you are losing the battle,  review the following ways to ensure full reimbursement for your services.
Choose your vision plans carefully. Keep the ones that reimburse you fairly for the service you provide and cancel the ones that don’t. Many of our colleagues have reported that deciding to drop a low-paying vision plan can be a difficult decision and afterwards gross fees may decrease, but they don’t regret their decision because total profit is higher. Working less and making more is often the end result.

If a patient comes in with a medical problem, submit the claim to the medical insurance, not the lower-paying routine vision plan. Diabetes is fast becoming an epidemic and monitoring patients for diabetic-related ocular disease requires a medical eye exam. Because so many new cases of diabetes are occurring everyday my staff inquires about diabetes when scheduling new patients and informs them they will likely receive a medical eye examination that typically will not be covered by their routine vision plan but will be submitted to their medical insurance. If you see a patient with diabetes you should perform a medical examination to evaluate for any ocular disease associated with diabetes. This typically requires more than a routine refraction and ocular health evaluation of the eye. If your routine vision plan pays $45 for an exam and the medical insurance plan allowable for a medical exam is $125 then you receive $80 less. Five patients per week multiplied by 52 weeks equal a substantial increase in fee revenues of $20,800 yearly.

Evaluate your fees and establish your fee schedule based on your cost of doing business/chair costs. Review the allowable fee schedules published by your Medicare/BCBS carriers and use them as part of your fee evaluation. You can look up your Medicare allowables at the following website: Under “schedule search” designate the year, state and locality to find the allowables for your practice location.
Editor’s Note: If  you do not know your chair cost (i.e., your break-even point) then you are setting your fees in the dark.

Practice optometry as you were taught in optometry school. Do as much as your license and clinical comfort level allows, and charge for everything you do. Any free service is undervalued by your patient, who expects to pay for your expertise and service. Epilation of lashes may seem like a simple procedure that many doctors perform without charging for it.  However the procedure code is 67820 and most Medicare carriers allow $45+ for this medical procedure.  A glaucoma suspect or patient with POAG may require monitoring including office visits, photos, TVF, Gonioscopy, serial tonometry and Pachymetry.

Day 1: 99204 Office visit, 92250 Fundus photos, 92083 TVF, 92020 Gonioscopy, Pachymetry 76514
Day 7: Optic Nerve OCT 92133 and Anterior Seg OCT 92132
Day 30: Office visit 99213 to evaluate IOP
Day 120:  Office visit 99213 to monitor IOP
Day 210: Office visit 99213, Fundus photos 92250, TVF 92083
Day 340: Office visit 99213 to monitor IOP

The following years will mimic the first year depending on patient’s outcome but most will require monitoring and treatment for many years. Annual revenue per glaucoma/suspect patient will likely fall between $500 to $1,000 yearly and allows you to pay off the investment in new technology, like an OCT, necessary to treat the disease.

Denied insurance claims should be researched and re-submitted until reimbursement is paid in full. If your billing specialist is not getting all of your claims paid, consider outsourcing your insurance billing to a billing service that has the expertise to push all of your claims through. Timely filing limits for Medicare claims are 12 months from day of service which means any claim submitted later than that will be denied by Medicare and only allows you to collect from the patient 20 percent of your fee or Medicare’s allowable depending on which one is lower. Many offices have a denial rate of 30 percent or higher due to uneducated or poorly trained billing specialists who lack the resources to successfully submit all claims. This may result in dramatic loss of income exceeding $100,000 depending on how busy the practice is.

Participate in Physician Quality Reporting System (PQRS), e-prescribing and meaningful-use with electronic health records. Incentive payments are available for all of these programs and currently many ODs are receiving these incentive payments. I completed my 90-day attestation late last year and received a check for $18,000 in January from Medicare. The payment is based on the provider being a Medicare provider, reporting that you performed requirements for meaningful use and equals 75 percent of your submitted Medicare allowable procedures up to $24,000. The maximum total incentive equals $44,000 per doctor over four years but you must complete the initial 90-day attestation period before the end of 2012.

Editor’s Note: The key is to do a cost analysis FIRST to make sure you have enough of a patient base to afford the lease or loan payment.
One last thought: Investing in new technology pays for itself. It makes you a better clinician for your patients and is reimbursable. A retinal camera makes monitoring diabetic retinal disease much easier, and if you are treating glaucoma, an OCT or scanning laser is essential. Last year alone one doctor in my practice generated over $19,000 in revenue from my Cirrus OCT, and fundus photos accounted for more the $15,000 in procedure fees. In addition, TVF fees were greater than $13,000 and these three instruments combined equaled 13 percent of my gross fees. Advanced instrumentation pays for itself if you are willing to make it happen.

Related ROB Articles

Four Key Steps toward Accurate Coding & Billing

Use EHR to Optimize Billing and Coding Process

Outsource HR and Billing to Improve Practice Quality and Efficiency

Eric Botts, OD, is the founder and president of OBC Billing Specialists. To contact him:

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