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.