The Top 10 Coding & Billing Errors of Optometry

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

A Duplicate Claim – 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 needs 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, and 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.

Ways To Prevent Medical Billing Fraud

Have you ever been a victim of medical billing fraud? Medical billing fraud, especially those related to insurance billing are far more common in practices than you would think. There are cases of willful fraud committed as well as those that are committed without even knowing it. In either case, the onus of the fraud and its legal consequences rests on the practice. How can you prevent these from taking place at your practice? Well, here are certain things you can do…

Same Procedure – Same Charge

This is one of the most common mistakes – charging different amounts for the same procedure based on insurance allowed. In order to avoid having to post insurance write-offs on a patient’s account, healthcare facilities often charge different patients dissimilar amounts for a similar procedure or treatment. Make sure that this practice is avoided at your facility. If you wish to offer a discount to a patient due to their financial hardship, do so by asking the patient to complete a financial hardship form. Remember, every patient needs to be treated the same and must be charged the same amount for the same procedure.

Patient Co-payments

Your heart wants to reduce the amount due from a patient undergoing financial hardship and you waive off the patients copayments – don’t! Your waiving off a patient copayment amounts to medical billing fraud, as it violates your insurance contract. This is also seen as taking unfair advantage over other practices and an attempt to woo patients to your practice. Ask the patient to fill the required form to avail a hardship discount.

Federal Laws

You may not be a lawyer, but it is important to know the laws that apply to your practice and follow them to the letter. For example, under the False Claims Act, it is illegal to submit claims for payment to Medicare or Medicaid, which you know, or should know, to be false or fraudulent. Any infringement of this law could lead to hefty fines, repayment of up to three times the amount and also criminal penalties. Another example is the Anti-Kickbacks Act, under which rewarding another physician monetarily for referred patients or receiving gifts or money in return for prescribing certain medicines is punishable under both civil and criminal statute. It makes good sense to be aware of these and other laws – and stay clear of infringing them.

Accurate Medical Billing and Coding

Entering the wrong code will likely cause your bill to be rejected. However, depending on the error, it could also be seen as ‘up-coding’ that is billing for a more costly procedure or service than the one provided. It may be a genuine mistake, but the onus will finally fall on you and you will need to prove that this was a mistake and not an intended medical billing fraud. With the implementation of ICD-10, the number of codes has gone up, thus creating more chances of such errors. Double check all bills before they are submitted and ensure that your staff does that too.

Credit Balance in Medical Billing

As the name implies, a Credit Balance happens when excess money is collected compared to the Charges for a service rendered by the Provider. This could be due to many reasons and has to be fixed while the final steps of medical claims processing are done. The Credit Balance could be due to an excess patient payment in the form of Co-insurance or Deductible; or it could be due to over-payments from the Insurance Payers. Let us analyze some scenarios and why it is important to be handled promptly:

Patient Credit Balance:

Patients might have paid an amount up front based on the assumption of what their Payers would cover. Once the medical claims processing is completed and the Payer pays in full, then the Patient’s payment is in excess. The physician billing solution can also call the patient and give the option of adjusting this excess against future visits or sending a check. But in either scenario, the Patient’s consent has to be obtained and is mandatory.

Payer Credit Balance:

Many a times the Credit Balance happens because of Over-payments by the Payers. Even the Patient’s Credit Balance is usually because the Payer paid more than anticipated. In medical claims processing, it is very important to handle the payments from Payers on priority. This not only projects the correct Cash flow as a result of the physician billing solution, but also prevents inflated AR. Some scenarios on Payer Credit Balances:

1) Both Primary and Secondary Payer pay as Primary
2) Payer pays more than Allowed amount by error
3) Cross-over errors, especially between Medicare and Medicaid
4) Privately purchased Plans – always pay as Primary, though there could be another Primary


In all these instances, there are very strict guidelines and time frames within which the excess money has to be returned either to the Payer or to the Patient, as the case may be. In case of Payer errors, the Payer has to be notified of the error within 30-120 days depending on the Payer. Failure to notify within the timeframe could be viewed as ‘Fraud’ by the Payer and the State with stiff penalties. If the Payers refuse the refund (as in the case of privately purchased Plans), then that money belongs to the Patient and the Patient has to be notified. The medical claims processing and physician billing solution providers have to keep these requirements in mind and process the Credit Balances on a daily/weekly basis to avoid any trouble for the Provider and the Practice.

Recoupments and Offsets:

Some payers would adjust the payments for current and future claims against Credit Balances owed to other Payers which are Recoupments. When the roblox download Payers adjust the payments for current and future claims against the over-payments made in the past in their own Plans, these are called Offsets.