Ophthalmology and Optometry Billing Basics

What are the special needs of an ophthalmology and optometry billing? Learn everything here...

Just as in other fields of medical specialty, ophthalmology and optometry also have very specific guidelines, rules, and regulations. You have to follow them all precisely for insurance to reimburse any kind of services.

Ophthalmology and optometry services are all services to the eye, including vision care and medical procedures done to the eye and ocular area. As such, for these services to be covered, they have to be performed by the right type of doctor.

Medicare will only consider payment of ophthalmology or optometry services if they're done by a provider whose scope of expertise is within these areas.

In other words: eye care services must be performed by eye doctors! If they aren't, they must be performed only with a medical diagnosis, and only when medically necessary.

Which services are covered?

Optometry and Ophthalmology services are all very specific. Because of this their coverage guidelines are also very specific.

These guidelines define the types of services that can be performed and reimbursed by insurance.

This being said, all insurance companies will have different service guidelines and coverage determinations, so in this case we will refer to Medicare guidelines.

The Medicare guidelines define other insurance guidelines in a very significant way, as they are basically the federal government's determination of reasonable and customary services, which should be paid for.

Furthermore, many ophthalmology and optometry services will be covered under vision insurance, which is not your typical medical insurance. People have to buy vision insurance separately from their medical insurance plans (just like dental insurance). Some employers don't even give the option of vision insurance.

Because of this, vision insurance plans will vary widely. They range from complete coverage of all eye related services, to one vision screening exam per year, to coverage of only medically necessary eye services performed by a physician (not an eye doctor).

Still other plans will require referrals or prior authorizations before the patient can be seen by the eye doctor.

On the other hand, Medicare doesn't require a specific vision plan, and covers all of the following listed eye services as medically necessary:

• Blepharoplasty: This is a surgery which improves normal eyelid functioning, reconstructs deformities, or enhances appearance. As such, it can be either cosmetic or reconstructive.

  Of course, the procedure may not be allowed if it is done for cosmetic appearances, but is covered if done for reconstructive purposes. These include correction of visual impairment, repair of anatomical defects, or relief of symptoms associated with blepharospasm.



• Capsule Opacification Following Cataract Surgery: Yes, it's a mouthful. Basically this surgery repairs a cataract surgery gone wrong. This happens when a cataract is removed but the repaired area opacifies (turns black) and makes it difficult to see.

• Diabetic Retinopathy Services: There are many specific services that are covered for diabetic patients who are at risk for retinopathy. These include:

  • eye exams
  • ophthalmoscopy
  • florescein angiography
  • and fundus photography (among others).

• Glaucoma Screening: Glaucoma screenings are covered for patients who are in a high-risk category. These include:

  • people with diabetes mellitus
  • people with a family history of glaucoma
  • African-American over age 50
  • and Hispanic-Americans over 65.

  Other restrictions apply to these services, including diagnosis and frequency.

• Keratoplasty: This is a surgery that treats lesions of the cornea and removes scar tissue from the visual field.

  This specific surgery uses a special laser and can only be performed by specially trained and certified ophthalmologic surgeons. Other keratoplastic and laser surgeries are allowed, but under different circumstances.

These are only a small number of the covered, medically necessary services performed by ophthalmologists and optometrists. The list of specifically covered services provided by Medicare is much longer, and much more specific.

For more information about whether or not your patient's services will be covered by their insurance you'll need to call their insurance company to make sure that it's considered medically necessary and doesn't need an authorization or a referral.

Optometry billing - a completely different world

Because of the separation of coverage (in other words, vision insurance and medical insurance), you can see how the field of ophthalmology and optometry billing is different to other medical specialties.

In eye services you're not billing for medical services - you're billing for eye services. They need to be covered under eye insurance and performed by an eye doctor.

Furthermore, ophthalmology and optometry services are very restricted per diagnosis, frequency, and by provider.

It's very important to understand all of the guidelines, rules, and regulations when it comes to billing and coding eye claims.

If you have strict attention to detail, like making sure all your t's are crossed and i's are dotted, then the fields of ophthalmology and optometry billing or coding may be for you. These offices are also not usually as busy as medical doctor's offices - the slower pace may also be a fit for you.

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