What problems face today's OD's in regards to medical, vision and patient billing?"

The Meeting is Set! 

opticXpress is pleased to announce our first ever webinar! The event will be a Q&A session featuring the president of opticXpress and special presenter, Arnaldo Martinez, O.D. of True Vision Optical in Miramar, Fl. 

Taking place at 8pm on May 12th, 2013, the meeting will last for one hour and will be an opportunity for you, as an optometrist or office manager, to present to us the challenges you face on a daily basis in regards to medical insurance billing, vision insurance billing and patient billing. Not only will you be able to post questions to us on how to better manage these challenges, but we hope you will take this opportunity to share ways that you handle these challenges in your office as well. 

We invite you to click the link below to register for this unique opportunity today!

SEE YOU SOON!

CLICK HERE TO REGISTER. SEATS ARE FREE AND GOING FAST, SO RESERVE YOUR SPOT TODAY!

Optometric Billing-Choose Your Billing Company Wisely!!

     It is no secret that we live in a world where the complexities of the insurance billing process leaves upon the door for fraud to run amok. Let me give you a personal example of just one such instance.

     In August of last year, my wife was seen by an emergency room physician who was a member of larger group that was contracted with her insurance company, Aetna, but they were not contracted to accept Aetna's HMO. However, given the fact that it was emergency care, my wife's out-of-network benefits dictated that the group must accept her and send them the bill. Without fail, the bill was submitted to Aetna within 72 hours for which they received payment in the amount of $413.12. Upon receiving this payment, the billing company for this ER group, changed the original procedure code and re-billed Aetna using the new procedure code. (Now, unless you bill a corrected claim to Aetna using their central fax number, you cannot bill corrected claims to Aetna. They are not set-up to accept corrected claims into their automated electronic adjudication system used to process normal claims. ) After receiving two denials for my wife's "corrected" claim, they then billed her for the difference in charge between the new procedure code, $605.22, and what they were paid for the original  procedure code, $413.12,a total sum of $192.10!
     My wife, being the diligent and honest woman she is, paid the bill and then handed it to me to file away. Upon reviewing it I noticed that she was being balance billed, a practice that is not necessarily illegal. I decided to listen to my "sixth sense", as she would call it, and look at her EOB to make sure the charges were legitimate. Sure enough, the EOB clearly stated that she was, under no circumstance, to be balance billed for this procedure! So I promptly called them and demanded a refund. After being on hold for quite some time, I was finally allowed to speak to a nice young girl who informed me that a mistake had been made and that a refund would be processed promptly. She told me that my wife could expect to see the refund posted to her account within 30 days.
    31 days later, the refund had still not been received. Another phone call to the billing company and another hour long wait turned up another representative who refused to let me speak to a supervisor but informed me that the refund had in-fact been processed and that it was pending a deposit to my wife's bank account. After getting off the phone with the billing company my wife decided to call her bank and follow up on the supposed deposit. Surprise, surprise: a refund was not pending, AT ALL!
    At this point my wife decided to try and get her bank involved. She opened an investigation, and the bank did its due-diligence and tried to resolve the matter with the billing company. After another 30 days, she was informed by the bank that there was nothing they could do to help.
    So now, just a couple of days before this writing took place, we were back at square 1. I decided to get involved again and sure enough, after another hour-long-wait, I was allowed to speak to Benjamin R. Oh Benjie, poor Benjie, he didn't know what he was running into when he started spewing off at the mouth to me that day! You see, Benjamin told me, again, that no supervisor could speak to me. He informed me further, that not only was my wife's refund not processed but that AETNA HAD REQUESTED A REFUND OF THE ORIGINAL PAID AMOUNT OF $413.12 AND NOW MY WIFE WOULD BE RESPONSIBLE TO PAY THAT BALANCE! This is where I went into "thermo-nuclear" mode against the billing company.
     I promptly hung up with Benjamin R. and called Aetna's member services. I detailed the events to aetna and sent them copies of everything, it was then that they discovered the billing company had tried to double bill Aetna for the emergency procedure and billed my wife instead when they had recorded 2 denials of the claim. Aetna took it upon themselves to call the billing company at this point and then conferenced me into the conversation at which time we were told, " A refund has been processed to your wife's account but it can take up to 90 days for it complete"!
   One word was my reply to them, "Unacceptable"!
   Promptly, I filed a complaint with Aetna's Fraud unit, the FTC and the Better Business Bureau. I then sent a copy of the complaints to the owner of Physicians group in hope that he would see who he is allowing to represent him and that he would do something about it.

   There is a recurring theme above. If you, as a medical practitioner, have a billing agency, staff-member, department or other entity in your employ, the words "unacceptable, hour-long-wait, it's the insurance company's fault, refused to let me speak to a manager, and fraud" had better never be used in the same sentence with them...EVER!!! These people represent your business, YOUR LIVELIHOOD on a daily basis, THEY REPRESENT YOU! These are the people you trust to provide CUSTOMER SERVICE to your patients and like it or not your patients are YOUR CUSTOMERS and without your customers, you have no practice.
    What does this all mean? Choose your billing company or billing personnel wisely! If you outsource, stay on top of them, audit them from time to time or enter a fake person with your address into your management system and have them send you a bill and see how they handle the situation when you call in; do whatever you have to do to make sure that your name and your practice are being represented fairly. Trust me, even though the FTC and BBB don't do anything about a claim 99% of the time, the complaint gets logged in a searchable online database that patients, potential patients AND INSURANCE COMPANIES all check on a regular basis. The database may not cause you to loose many patients but if one of your top insurance payers decides to check up on you and sees one of those complaints, kiss your contract with them goodbye. 

    We live in the digital age and word of mouth is everything. Make sure the words being used to represent you are the right ones.

opticXpress is a reputable optometric billing company. We treat everyone fairly and we always make sure that your practice is represented in the best possible manner! Contact us today. 

Optometric Billing-The Future of Optometry

All the time I am confronted with OD's who complain or fear the rise of the prominence of Vision plans, decreases in reimbursements from Medicare and other Insurance companies and so forth. However, when I say to these docs "What are you going to do about it?" the answer is usually...SILENCE.

In my opinion, the only way to effect change is to be change. Speak up for what you believe, fight for what you want/need and find a way to be seen and heard. The funny part is that in today's world, it is so much easier to be heard AND seen than ever before if for no other reason than Google (blogger) and Youtube.

Below is a video I found on You Tube. Many of you may have seen this, many may have not. What is most important about this clip is that the people that you will see in it may be very prominent members of the optometric community while others are just getting started. What they all have in common...THEY ARE SPEAKING OUT IN DEFENSE OF THEIR PROFESSION AND MAKING THEMSELVES SEEN AND HEARD.

What will you do going forward? Will you speak out about your profession too? Talk back below and let us know and remember, opticXpress is always here to help...contact us today.

Optometric Billing-Some Coding Tips, OCT, GDX, Fundus Photos, ETC

Optometric Billing-Billing for an Exam on the Same Day as a Surgical Procedure Such as Dry Eyes or Epilation

It has always been my opinion that in order to bill for an exam on the same day as providing a surgical procedure, such as dry eyes, that one would have to have notated evidence that the examination portion of the encounter was not in fact related to the surgical procedure.  It turns out that after some further research into my coding guidelines this is not just my opinion, it is fact. Let's take a look at how this should be handled.

IE: The patient came into the office for a routine exam or yearly check-up and at that time it was decided that the patient qualified for punctal plugs or epilation. (The plugs would be rare in this instance as it is now necessary to try every other treatment possible BEFORE proceeding with inserting the plugs). 

So, in the example above, the physician would note that "the patient was in for a yearly check up and during the course of exam the patient described to the physician that though the drops he has been using for his dry eye syndrome help somewhat, they are still relatively ineffective at times and he would like to know if there is anything else he could try. At this time the physician offers the option of punctal plugs as they have been shown to be a very effective, though minimally invasive, method of treating the patient's condition. "

If  the condition above, or any other combination of supporting evidence, is present you now have a justifiable basis for billing the insurance company for 1) A comprehensive examination 2) Punctal Plugs. The example above would be billed in a manner similar to the following:

1) 92014-25 (25 modifier means the exam is a separate service from the actual plugs themselves)

2) 68761 (one plug in either eye) or 68761-50 (1 plug in both eyes) or 68761-51 (2 plugs in the same eye) or better still 68761 E1 (E1 meaning it was the upper left lacrimal duct E3 would be upper right and E2E4 are lower left and right respectively). SEE BELOW 

If the condition in the above example is not met, by no means should you bill an insurance company for an exam AND a surgical procedure.At this point, it is understood that the procedure for plugs or epilation etc. includes any examination that need be done. Furthermore,  UNLESS a patient comes into the office for an exam during the 10 DAYS subsequent to the punctal plug procedure for something UNRELATED to the previous procedure you cannot bill the patient's insurance for any further items. In this case, you would bill the proper examination procedure code, followed with a -24 modifier (unrelated E/M procedure during post-op period) SEE BELOW

CLICK HERE TO VIEW THE OFFICIAL MEDICARE COVERAGE INFORMATION FOR BILLING PUNCTAL PLUGS.

If you would like to make your billing easier and more effective, try contacting opticXpress today by clicking here!

Optometric Billing-Billing For Punctal Plugs

This was burried in our internal notes and is article written by  John Rumpakis, O.D., M.B.A., Clinical Coding Editor. You can find the original text for this article by clicking here.

"Signs and symptoms of dry eye syndrome are often discovered during a comprehensive exam. When further testing is indicated, this may be best done as a follow-up evaluation. This evaluation for dry eye syndrome most likely involves several examination techniques and ancillary tests. These tests, which do not have separate procedure codes, include:

• Patient history (dry eye surveys, symptoms, circumstances, etc.) 

• Tear film break-up time (TFBUT) • Schirmer testing (I&II)  

• Cotton thread or phenol red thread testing 

• Sodium fluorescein, lissamine green and/or rose bengal staining  

• Tear prism evaluation  

• Evaluation of lid wiper epitheliopathy

• Biomicroscopy and examination of ocular surface and lid margins

These tests help you formulate the diagnosis. The appropriate diagnosis code is usually dry eye syndrome (375.15) or keratitis sicca (370.33). Sjögren’s syndrome/keratoconjunctivitis sicca (710.2) is also a possibility, although you should be familiar with your carrier’s requirements prior to initiating any therapy.

In general, before contemplating either surgical or prescriptive treatment, you should have a well documented record of palliative therapy with an artificial tear protocol. The failure of the artificial tear treatment is what provides the medical necessity to proceed to more invasive treatment.

Once you’ve made the diagnosis of dry eye and formalized a treatment plan, several subsequent visits are typically necessary to evaluate the treatment plan. Both the diagnostic and treatment visits are billed using the appropriate office visit codes only. Keep in mind that if you perform the diagnostic examination on the same date as the comprehensive exam, it is not billable as a separate/distinct visit in addition to the comprehensive examination. Follow-up visits to assess the effectiveness of treatment, to alter or to add to the treatment plan are billed using 99212, 99213 or 92012. 

If you decide the patient requires punctal plugs, the billing is the same for temporary diagnostic plugs and permanent plugs. The supply of the punctal plugs is typically included in the insertion code. The insertion procedure is billed per plug in one of two ways. Here is the first method: 

• One plug: 68761  

• Two plugs, different eyes: 68761-50 (billed at 200% of one plug) 

• Two plugs, same eye: 68761-51 (billed at 200% of one plug) 

• Three plugs: 68761-50 (billed at 200% of one plug) and 68761-51 (billed at 100% of one plug) 

 • Four plugs: 68761-50 (billed at 200% of one plug) and 68761-50-51 (billed at 200% of one plug) 

The “multiple surgery rule” applies, so the payment is typically 100% for first plug, 50% for the second plug, and 25% for each of the third and fourth plug. The -50 modifier indicates a bilateral procedure on the same eye and the -51 modifier indicates multiple procedures on the same eye. See Appendix A in your CPT book for further details. 

The second method for billing punctal occlusion is adding the E modifiers to the surgical code to designate which puncta are being occluded. Bill for each plug on a separate line using the appropriate E modifier: 

• E1: upper left  

• E2: lower left  

• E3: upper right 

 • E4: lower right 

The global period for punctal occlusion is 10 days. So, if a patient returns within that period for a follow-up visit related to the punctal occlusion, then that visit is included in the insertion fee. However, if a patient returns for an unrelated problem, then that office visit must be billed using a -24 modifier (unrelated evaluation and management during a postoperative period) in order for you to be compensated for that encounter. "

We would like to thank Dr. Rumpakis for his continued contributions to Medical Coding. His work has proved to be very valuable to our cause as well as many OD's around the country.

CHECK OUT OPTICXPRESS TODAY AND TAKE THE NEXT STEP TO MAKING YOUR BILLING MUCH EASIER! 

Optometric Billing- Does Medicare Cover Routine Eye Exams?

I get this question all the time, sometimes doctors even demand that I "respect their authoritah" (Eric Cartman pun intended) and trust them when they tell me that Medicare Pays for Routine Eye Exams.

Simply put, MEDICARE DOES NOT PAY FOR ROUTINE EYE EXAMS, EXCEPT FOR PATIENTS WITH DIABETES. 

"Medicare Part B (Medical Insurance) covers a yearly eye exam for diabetic retinopathy by an eye doctor who is legally allowed to do the test in your state." link

That being said, if you try to bill Medicare using a V72.0, 367.21, 367.0, 367.4,367.1 DX Code as your primary DX code, expect not to get paid; and if Medicare doesn't cover it, chances are the patient's secondary may not pick it up either, although this is not a definite rule as it varies by payer and patient plan.

By the way, for those docs and staff out there that think you are being paid for routine work because the EOB says you were paid for a "92004 and 92015"....YOU ARE MISTAKEN AND YOU MUST LEARN TO RESPECT MY "AUTHORITAH" !