Ophthalmology Billing Services are a dime a dozen!

However finding a provider of these services that actually knows how Specific Optometry and Ophthalmology services are and much different in that optometry services are based around vision primarily and billed under vision policies and Ophthalmology is surgical in nature and is billed under medical services and the guidelines of their coverage is like finding a needle in a haystack! That is probably why you have actually read thus far.


Most if not all insurance companies have different coverage schedules its important to note that without noting these schedules and having a bit of systematic approaches to the actual EOB data it can be virtually impossible to know which policies will pay what in the different states.


  Most un-sophisticated ophthalmology billing companies rely heavily on Medicare guidelines to define other insurance guidelines this is a bad habit and lazy practice to adopt in that, as they are the federal government's determination of reasonable and customary services they in no ways by any means have remotely the same code sets and or compounding actions that most out of network providers allow and or cover for hence limiting the scope of hedging “bets” on this or that policy…. No one that runs a successful Optometry practice likes to make bets in the dark as most heavily rely on the light to see.


Vision insurance in not the typical insurance we see in most of our practices that we bill for however it should be noted that a dozen or so vision policies we saw this year actually paid out higher rates than we we saw top Out of Network plans pay. Which gave these practices a great heads up on their Marketing and Branding campaigns this coming quarter on where and how to spend budgets.

  • Blepharoplasty: When Ophthalmology billing companies try to bill out for some of the procedures under Blepharoplasty guidelines like CPT/HCPCS Codes -15823, 15822, 67900, 67924 they miss the mark on most of the compounding codes that show the Events in a monitoring state (we have added a few basics here but have withheld proprietary code sets for obvious purposes) CPT 93268, 93270,93271, 93272
  • Obviously the doctor or practitioner needs to ask the correct questions to align the coverage and prove that the surgery is needed outside of cosmetic such as client has shown anatomical defects and in need of repair of anatomical defects, or relief of symptoms associated with blepharospasm, but this is all standard procedure and most licensed practitioners should know what these symptoms include and or look like.
  • Capsule Opacification Following Cataract Surgery: When cataracts are removed but the pupil remains black many practices fail to document and loose out tremendously on potential compounding components in billing such as H26.411 - H26.413 H26.491 - H26.493 which can also be set in place with revenue codes for the bilateral and right eye rings
  • Diabetic Retinopathy: We all know the services, but does your billing department know that for the following there are actually multiple extensions that can be added such as
    • • Ophthalmoscopy EO
    • • florescein angiography There are actually multiple modifiers not just 92240 -50 modifier X1 unit.2. 92240 - LT
    • • fundus photography Correct coding of 362.0X dictates primary coding with 250.50–250.51, however providers will not release payment unless 362.0X is also reported we saw a practice almost go out of business for this error from their billing company.
  • Glaucoma Screening: Here are a few more examples of higher allowable as long as the criteria is met here are some examples of criteria that reaches and or meets higher levels of necessity
    • • diabetes mellitus
    • • people with a family history of glaucoma
    • • African-American over age 50
    • • Hispanic-Americans over 65.

  • Keratoplasty: Billing out surgical procedures that involves a laser seems like a straightforward process however what most billing groups do not know and or understand because none of them actually worked in and or around laser surgical centers is that
    • • 65710           keratoplasty (corneal transplant); lamellar; Can not be billed out under CPT 65730
    • • 65730           penetrating (except in aphakia); can only be billed under rev code if it isn’t psuedo
    • • 65750           penetrating (in aphakia); Call us to find out we are putting out too much game
    • • 65755           penetrating (in pseudophakia) Same as above

Our team at Infallibill wants to engage with you and just focus on the solution not the old cob webs in the closet but rather the future we are professionals and will treat your practice professionally every step of the way! Contact us today and we will walk through some strategies that can help you today starting with friendly advice and moving onto a lasting successful business relationship.
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(888) 394-3332