Insider Tips for Faster Eye Care Payments
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No one likes to see a denied claim from an insurance or vision plan payer. A denied claim is lost or delayed revenue for your eye care practice.
Researching and resubmitting denied claims can lead to long, frustrating hours trying to figure out why the claim was denied in the first place. That’s why nearly 65% of denied claims are never reworked by providers.
Let’s look closely at common coding denials, reasons, and how you can establish a proactive solution to increase your business revenue.
To Bundle or Not to Bundle?
Bundling occurs when certain procedures or services are included (or “bundled”) within the definition of another service using CPT® codes.
Why is unbundling a problem?
Some providers may bill a bundled service separately for higher reimbursement. This practice, known as “unbundling,” is forbidden and can lead to compliance issues and denied claims if the medical necessity cannot be established.
Mutually Exclusive Services Example:
Let’s review Mutually Exclusive Services that are always bundled together. If 92250 (Fundus Photography) is billed along with the following services:
92133 (Computerized ophthalmic diagnostic imaging (e.g., optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; optic nerve).
92134 (Computerized ophthalmic diagnostic imaging (e.g., optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina).
The above services can only be unbundled if there is a clear case of medical necessity and supported documentation is provided to establish the necessity.
Additionally, CPT® codes 92133 and 92134 cannot be billed together on the same date. If both are reported, one of the codes will be denied for bundling and cannot be unbundled.
Refraction Example:
Under CPT® code definitions, refraction is not included in any 92000 or 99000 medical eye examination and can be billed as a separate service. However, Medicaid and many vision plans do bundle the exam with refraction.
How to know what applies:
Review each plan’s coding and billing policies before providing services.
Check the patient’s Explanation of Benefits (EOB) for bundling denials.
Bottom line:
Bundling rules vary by payer. Taking the time to verify coverage before billing will protect your practice from compliance violations and reduce the likelihood of claim denials.
TRICARE Billing Tips
Always make a copy of the patient’s Military card (front and back). This serves as the TRICARE identification. Pay close attention to the patient’s expiration date on the card.
TRICARE has transitioned away from using the sponsor’s Social Security Number (SSN) for identification and claim purposes. However, while some systems may still accept the SSN, the DoD Benefits Number (DBN) is the preferred identifier. If you use the SSN, always use the Sponsor SSN and Sponsor Name. For example, if a patient is the spouse of a retired military veteran with TRICARE Prime, use the veteran’s SSN, not the spouse’s. Otherwise, the claim will be rejected as “patient not on DEERS.”
Confirm the patient’s address is within the correct region (West or East) and update as needed.
Use the DBN for verifying patient eligibility and submitting claims.
Have the patient complete an Advance Beneficiary Notice of Noncoverage (ABN) if there’s a chance services may be denied so you can bill them later.
Medicare Billing Tips
Are you noticing more Medicare claim rejections or denials appearing in your inbox? Keeping up with Medicare regulatory and coding changes and declining reimbursements is a constant challenge.
Check out our blog: 7 Medicare Billing Dos and Don’ts to Guide Your Eye Care Practice.
Common Medical Billing Modifiers
Modifiers provide payers with additional context for why a service was performed. They’re essential for accurate reimbursement but can be costly if misused.
Learn more in our blog: How (and How Not) to Use Common Medical Billing Modifiers.
Claim Denial Reason Codes
Denials typically fall into three categories: administrative, clinical, and policy—with administrative errors being the most common.
Our blog, Mastering Claim Denial Reason Codes, breaks down top denial codes and actions you can take to prevent them. We share real-world results where Fast Pay Health helped practices cut reimbursement times from 45–60 days to just 15 days.
Get Paid Faster with Fewer Coding Denials
Fast Pay Health coders and billing consultants have extensive experience in optometry and ophthalmology coding. We:
Scrub claims to remove errors before submission
Follow CPT® and ICD-10 coding best practices
Apply correct modifiers to avoid denials and rejections
Maintain 100% HIPAA compliance
Our billers ensure that your claims are thoroughly reviewed and error-free before we submit them. The result? Fewer denied claims and a healthier, more predictable cash flow for your practice.
Request a free practice analysis today and start reaping the benefits of fewer denied claims and faster payments.