Running an optometry practice means juggling patient care, insurance rules, and an ever-changing billing landscape. Even small mistakes in coding, claim submission, or documentation can quietly drain your revenue month after month. The good news? Most of these leaks are entirely preventable once you know where to look.
Below, we’re breaking down the top seven billing errors we see most often in optometry practices and what you can do today to stop them.
1. Using the Wrong Exam Codes
Mixing up eye codes (92XXX) and E/M codes (99XXX) is common, but the distinction matters. Eye codes are used for comprehensive eye exams, even when a medical component is involved. E/M codes are typically used when the encounter involves purely medical management (such as monitoring diabetic retinopathy or adjusting glaucoma treatment) without a comprehensive eye exam.
Tip: Code based on the service provided and documented, not on which pays better. Incorrect code selection can trigger audits or denials
2. Forgetting Modifier 25 or 59
Modifiers 25 and 59 are necessary when you perform genuinely separate services on the same day, provided that the documentation supports this. Modifier 25 indicates a significant, separately identifiable evaluation and management (E/M) service performed on the same day as a procedure. Modifier 59 indicates a distinct procedural service.
Tip: Don't reflexively add modifiers to force payment. Instead, ensure your documentation clearly shows why the services were separate and medically necessary. Inappropriate modifier use can trigger audits.
3. Refractions Billed Incorrectly
Refraction billing varies significantly by payer. Medicare does not cover refractions, but some commercial insurance plans do; therefore, it is crucial to verify benefits before the appointment. The problems arise when practices either assume all insurance covers it (leading to patient surprise bills) or assume none do (leaving money on the table).
Tip: Verify eligibility and benefits for each patient before their visit. Train your front desk to explain refraction coverage upfront and collect fees at the time of service when it's not covered. Document the refraction conversation in the patient's chart to avoid confusion later.
4. Missing Medical Necessity in Documentation
Even the best coding can’t save a claim that lacks medical necessity documentation. Every diagnosis, test, and treatment must clearly tie back to the patient’s condition.
Tip: Have your team conduct periodic documentation reviews, especially for visits related to chronic disease management.
5. Late Claim Submission
Each payer has its own filing limits, often as short as 90 days. Miss that window, and the revenue is gone for good.
Tip: Establish a weekly billing cycle and use reports to flag unbilled visits before it’s too late.
6. Overlooking Denials and Write-Offs
Many practices write off denials or underpayments instead of investigating the cause of the issue. Over time, this adds up to thousands of dollars in lost income.
Tip: Track denials by reason code and follow up systematically. Not every write-off is justified; some are recoverable revenue.
7. Ignoring Credentialing & Enrollment Updates
If a provider isn’t correctly credentialed or revalidated, payers will deny every claim, sometimes for months without you realizing it.
Tip: Keep a live credentialing tracker for each provider and payer. Assign someone to check payer portals monthly for updates.
How Much Are These Errors Costing You?
The typical optometry practice loses between 5% and 15% of its total collections due to avoidable billing mistakes. That’s the difference between staying flat and funding your next staff hire, new equipment, or expansion.
Final Thought
Minor billing errors add up quickly, but so do minor improvements. Start by addressing just one or two of these issues each month. Within a quarter, you’ll notice measurable improvements in cash flow, fewer denials, and smoother patient billing.
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