According to the Definitive Healthcare report, around 78.6% of hospitals in the USA have successfully implemented telemedicine solutions within the last few years. Although its integration in ophthalmology has been more gradual, the importance of telemedicine is still evident in this specialty.
With such virtual consultations, practitioners can expand access to eye care for timely follow-ups and even disease monitoring. However, as an eye care specialist, you may face challenges when it comes to ophthalmology medical billing for telehealth services.
While majorly focusing on patient care, a practitioner may fail to keep pace with inconsistent payer policies and evolving coding requirements. To optimize billing within this specialty, we will dig deep into the details of this process.
Detailed Steps to Bill for Telemedicine Services in Ophthalmology Medical Billing
Ophthalmology telehealth medical billing requires a precise approach to ensure full compliance. From verifying patient eligibility to submitting claims with the right codes, each step demonstrates its importance. Here, we will break down ophthalmology billing and coding workflow to guide you through every technical detail.
1. Verify Patient Eligibility for Ophthalmology Billing Services
Prior to providing any ophthalmology billing services, confirm the patient’s insurance coverage and specific telehealth eligibility. With this step, practitioners get to avoid denials and understand all payer-specific rules.
Implementing this step is easier by simply accessing the insurance provider’s portal, such as Aetna or UnitedHealthcare. In addition, in-house or outsourced billing teams can also verify this information through EHR platforms, such as Athenahealth. All they have to do is enter the patient’s details to verify the following things:
- Telehealth coverage
- Type of telehealth allowed from the options, including audio-only or audio + video
- Eligible CPT and HCPCS codes
While doing so, providers or their billing team also have to verify the payer’s guidelines to avoid any complications. For example, Medicaid only accepts the 95 modifier, as the GT one is no longer valid for their telehealth coverage.
2. Provide Ophthalmology Telehealth Service and Document Everything
Upon verification of eligibility, proceed to conduct the actual telehealth appointment. As an ophthalmologist, utilize the below HIPAA-compliant platforms for this purpose.
- Zoom for Healthcare
- Doxy.me
- VSee
- Doximity and more
Ophthalmology billing teams can follow up on allergic reactions or perform medication adjustments using these platforms. To comply with payer policies and audits, eye specialists have to document the entire process by adding the details like provider and patient locations, timings, findings, and treatment plans.
3. Pick Appropriate CPT Codes for Ophthalmology Billing
To code the documented telehealth visit, billers need to be aware of the right ophthalmology medical billing codes. Generally speaking, telemedicine services fall under two categories, as explained below.
A. Real-Time Telehealth (Synchronous Video Visits)
Such visits usually involve face-to-face video interactions between the provider and the patient. This most commonly reimbursed type of telehealth service is widely accepted by Medicare and most commercial payers. For such interactions, take guidance from this code cheatsheet to avoid any complications during ophthalmology billing and coding for telehealth.
| Codes | Description | Use Case in Ophthalmology |
| 99211 – 99215 | Established patient E/M services (Followed by Medicare) | 99213 used for prescription drug management of stable glaucoma. 99214 applicable when there is a need to change the treatment plan of unstable glaucoma. |
| 98000 – 98007 | Evaluation and management services for new and established patients (Applied starting from 2025) | 98000 to 98003 for eye evaluation of newer patients. 98004 to 98007 used for E/M services of established patients. |
| 92002 – 92014 | Eye visit codes | 92002 – 92004 for newer patients. 92012 – 92014 for established patients. |
| G2010 | Remote evaluation of images or video | Patient sends photo of red eye for physician to review during video examination. |
B. Audio-Only Telehealth (Phone Visits)
While performing telehealth medical billing for ophthalmology, utilize the following codes only when video services are not available. However, coverage varies significantly by payer, and Medicare limits its use after the PHE (Public Health Emergency) ends.
| Codes | Description | Timings for Ophthalmology Visit |
| 98008 – 98011 | E/M services for new patients | 98008 for 15 minutes call 98009 for 30 minutes call 98010 for 45 minutes call 98011 for 60 minutes call |
| 98012 – 98015 | Ophthalmology evaluation and management services for established patients | 98012 for 10 minutes call 98013 for 20 minutes call 98014 for 30 minutes call 98015 for 40 minutes call |
4. Add the Correct Modifiers for Telehealth Services
To provide extra information while delivering ophthalmology medical billing services, medical coders add modifiers. The purpose of these two-character modifiers is to add extra details about the procedure performed without changing the definition of CPT codes.
In the ophthalmology specialty, these supplemental codes explain how the eye is being treated, multiple procedures, and other additional information. Explore the following modifiers explaining different procedural variations when it comes to remote eye care.
| Modifier | Description | Use in Ophthalmology |
| 95 | Telemedicine services are provided through real-time interactive audio and video system | Used for eye consultations from diseases, such as glaucoma, through video calls |
| GT | Synchronous audio-video (older format replaced by 95) | Utilized sometimes by legacy payers for virtual eye care services |
| 93 | Telehealth service via interactive audio-only telecommunication | Phone visits for dry eye management |
| GQ | Remote telehealth service provided through image or video but not in real-time | Retinal imaging interpretation by MD from a remote location |
Note: Medicare doesn’t use the GT modifier anymore for telehealth services, as they now utilize Modifier 95 instead. However, some private insurance plans might still accept GT, so it’s a good idea to check with each payer.
5. Assign the Correct Place of Service (POS) Code
After exploring how to add modifiers to code while providing the ophthalmology billing service, let’s further learn ways to refine this coding process. To do so, you can make use of the Place of Service code to tell the insurance payer where the patient was located when they received care.
As reimbursement rules can vary based on the patient’s location, billers and providers should utilize these codes to avoid any payment errors.
| POS Code | Description |
| 2 | Remote ophthalmology services provided in locations other than in the patient’s home |
| 10 | Telehealth services are delivered to the patient when he is present at his home |
Example in Ophthalmology Telehealth
Let’s say a glaucoma patient joins a follow-up appointment over Zoom from their home. As an ophthalmologist, you ask him about eye pressure and adjust the care plan. Since it’s a telehealth visit and the patient is at home, your billing team needs to utilize POS code 10.
6. Submit and Track Telehealth Claims
Upon completing documentation and coding, you have to submit the claim using any clearinghouse. Generally speaking, these clearinghouses act as a middleman between healthcare providers and insurance companies.
Overall, their main job includes ensuring that the claims sent by the coding team of providers have no issues before they are sent to the insurance companies. Once you submit the claim, actively monitor its status to ensure timely reimbursement. For this purpose, the medical billing team needs to look review the EOB or ERA issued by the payer.
7. Effective Denial Management
If you face denial issues after submission, explore and modify common reasons, including missing modifier or unsupported telehealth code. To support you in resolving these issues, we will guide you through troubleshooting the most common telehealth billing errors and provide solutions to ensure your claims are corrected.
Troubleshooting Common Errors During Ophthalmology Billing and Coding
As mentioned, denials can still occur even after following best practices mentioned in this guide. When a claim is rejected post-submission, take guidance from these major troubleshooting solutions to optimize medical billing for ophthalmology.
Error 1. Use of Incorrect Modifiers
Many ophthalmology practices incorrectly use Modifier GT instead of 95 when not supported by the payer. In addition, few eye care specialists forget to use audio-only ones, such as 93, for telephonic visits.
Solution: To avoid any inconveniences, always verify the payer-specific telehealth modifier guidelines. Only use Modifier GT if a specific private payer still requires this outdated one.
Error 2. Wrong CPT Code Selection for Telehealth
When you select outdated CPT codes, such as the 99211 to 99215 series, you will face claim denials after submission.
Solution: As an eye care provider, you need to be updated on current CPT and HCPCS codes allowed for ophthalmology billing.
Error 3. Incomplete Documentation of the Telehealth Visit
While documenting remote visits, ophthalmologists may miss key details like patient consent and service location. Due to this error in ophthalmology medical billing, practitioners will suffer from problems in their revenue cycle management.
Solution: You have to make sure the documentation includes every important detail that will help you get paid. Never forget to add a HIPAA-compliant platform used for remote services, patient provider location, and other such parameters.
Join Hands with Transcure to Prevent Every Ophthalmology Billing Error
Feeling overwhelmed while juggling patient care and navigating ophthalmology billing and coding requirements? That’s a clear sign that it’s time to streamline your revenue cycle management with expert help. For this, take guidance from an experienced team at Transcure, as we specialize in ophthalmology billing.
With a 98% first pass clean claims rate, our experts take pride in providing error-free billing and coding service. As an eye care specialist, you will experience over 20% growth in your revenue after letting us handle your revenue cycle.
Why Do Eye Care Specialists Trust Transcure?
To help ophthalmologists smoothen their RCM, our experts facilitate you in these manners.
- Accurate CPT and ICD-10 coding for all procedures to reduce audit risks
- Maintain compliant and detailed clinical records for every telehealth visit
- Smart modifier assignment to get you paid fully and fairly
- Perform internal audits to catch inconsistencies before claims are submitted
Conclusion
In summary, remote checkups facilitate patients’ getting eye care from the comfort of their homes. However, practitioners usually face some challenges when it comes to ophthalmology medical billing.
While picking the proper codes and adding correct modifiers, every step matters. Therefore, you have to avoid small mistakes that can lead to delays or denied payments. That’s why many eye care specialists turn to experts, such as Transcure, for help. Our team takes care of your ophthalmology billing services so you can focus on your patients.
Frequently Asked Questions (FAQs)
Which ICD-10 codes are most commonly used in ophthalmology billing??
Some common codes representing diagnosis in eye care include:
- H40 to H42: Glaucoma.
- H10 to H11: Disorders of conjunctiva
- H25 to H28: Disorders of lens
- H55 to H57: Other disorders of eye and adnexa
How can ophthalmology billing services help reduce claim denials?
Through optimized billing processes, you can reduce claim denials by ensuring accurate CPT and applying the correct modifiers. These services also try their best to follow payer-specific telehealth rules and track claims actively. All of this will assist you in reducing human errors and speeding up reimbursement from insurance companies.
Is modifier GT still valid in ophthalmology billing and coding?
As far as Medicare is concerned, this modifier has become outdated, as it was replaced by 95. However, GT may still be accepted by certain commercial payers and legacy insurance companies.
How can you code for ophthalmology?
To code for this speciality, start with clear documentation of the patient visit. Moving forward, you have to choose the right CPT codes, depending on the service. Always remember to add the right modifiers and place of service codes before submitting the claims.
