Ophthalmology billing
Ophthalmology billing services
We handle billing for ophthalmology practices, from medical eye exams and diagnostic testing to cataract surgery and intravitreal injections. Claims go out within 24 hours of receiving charges, every denial is worked within 5 business days, and pricing starts at 2.5% of collections.
- Eye visit codes (92002–92014) vs E/M chosen per payer
- Injections billed with the drug code, units and JW/JZ modifier
- Cataract global periods, RT/LT and co-management modifiers
Why ophthalmology billing is different
Eye care has two code sets, two kinds of insurance and costly drugs
Ophthalmology practices choose between eye visit codes and E/M codes, bill medical and routine vision to different payers, and buy expensive drugs they must be paid back for. Each step has its own rules.
Eye codes vs E/M
Ophthalmologists can bill general ophthalmological services (92002, 92004, 92012, 92014) or standard E/M codes. The better choice depends on the exam, the documentation and the payer. We check both before coding.
Medical vs routine vision
A routine eye exam may go to a vision plan while a visit for a medical problem such as glaucoma or diabetic eye disease goes to medical insurance. The reason for the visit and the diagnosis decide which payer is billed.
Refraction
Refraction (92015) is not covered by Medicare and many medical plans. Practices usually collect it from the patient, so it needs to be separated from covered services on the claim.
Cataract surgery
Cataract surgery carries a 90-day global period. Each eye needs RT or LT, a second eye inside the first eye’s global period usually needs modifier 79, and co-management with an optometrist uses modifiers 54 and 55.
Intravitreal injections
Injections (67028) are billed with the drug’s HCPCS code and the correct units. Medicare requires JW for discarded drug from single-dose vials and JZ when none was discarded. Many plans require prior authorization or step therapy for these drugs.
Diagnostic testing
Tests such as OCT, visual fields and fundus photography are billed per session, some per eye, and some cannot be billed together on the same day. Medical necessity and frequency limits vary by payer.
Common codes
Ophthalmology codes we review on every claim
| Code(s) | What it is | What we watch for |
|---|---|---|
| 92002 / 92004 / 92012 / 92014 | New and established eye exams (intermediate / comprehensive) | Exam elements documented; compared with E/M for the payer |
| 92015 | Refraction | Usually patient responsibility; kept apart from covered services |
| 66984 / 66982 | Cataract surgery with lens implant (standard / complex) | Complex criteria documented; RT/LT and global period |
| 67028 + drug J-code | Intravitreal injection plus the drug | Drug units, JW/JZ modifier, prior auth and step therapy |
| 92133 / 92134 | OCT of the optic nerve / retina | Not billed together on the same day; frequency limits |
| 92083 | Visual field exam | Diagnosis that supports medical necessity |
| 66821 | YAG laser capsulotomy after cataract surgery | Timing relative to the cataract global period |
Codes and rules change. We check current CPT guidance and each payer’s policy before submission.
Common denials we prevent
Ophthalmology denials we stop before they happen
Ophthalmology denials usually come from payer mix-ups, drug billing errors and global period conflicts. We check each before the claim goes out.
- Routine vision exams billed to medical insurance, or medical visits billed to a vision plan
- Injection drug units that do not match the dose, or a missing JW/JZ modifier
- Injection drugs given without a required prior authorization or step therapy record
- Second-eye cataract surgery billed without modifier 79 or laterality
- Diagnostic tests billed together that the payer treats as mutually exclusive
- Refraction billed to Medicare as if it were a covered service
What we handle
Everything between the exam lane and the payment
- Insurance eligibility and benefits checks for medical and vision coverage
- Charge entry and coding review of exam codes, drug units, laterality and modifiers
- Claim submission within 24 hours of receiving charges
- Payment posting and ERA reconciliation
- Denial correction, resubmission and appeals within 5 business days
- A/R follow-up on unpaid and underpaid claims
- Commercial, Medicare and Medicaid credentialing for ophthalmologists and optometrists
- Patient statements and balance tracking
- Monthly reporting on collections, denials and A/R
Pricing
Clear pricing for ophthalmology practices
Billing starts at 2.5% of collections, or a flat monthly fee. There is no setup fee and no long-term contract. Credentialing starts at $80 per payer, and 5 commercial payers are credentialed free when you sign up for billing.
Common questions
Should we bill eye visit codes or E/M codes?
It depends on the visit. Eye codes (92002–92014) have their own exam requirements, while E/M codes are based on medical decision making or time. We look at the documentation and the payer’s policy and use the code the note supports.
How do you bill intravitreal injections?
We bill 67028 for the injection and the drug’s HCPCS code with units that match the dose given. For Medicare, single-dose vials also need JW for discarded drug or JZ when nothing was discarded. We check prior authorization and step therapy rules first.
How do you bill cataract surgery on the second eye?
Each eye is billed with RT or LT. When the second eye is done inside the first eye’s 90-day global period, it is usually billed with modifier 79 so the payer knows it is a separate procedure.
Do you bill co-management with optometrists?
Yes. The surgeon bills the surgical care with modifier 54 and the optometrist bills post-operative care with modifier 55, with a transfer of care documented. We make sure both claims line up.
Can you bill both vision plans and medical insurance?
Yes. We check both types of coverage before the visit and bill the plan that matches the reason for the visit and the diagnosis.
Is ophthalmology your main specialty?
No. Our core focus is behavioral health, and we bill ophthalmology and other specialties with the same team, the same promises and CPB-certified billers on the team.
Guides from our team
Learn more before you decide
Top 10 Reasons for Medical Claim Denials (And How to Fix Them Fast)
The 10 most common reasons for medical claim denials, what each one costs your practice, and the exact fix for each. Plus a denial-prevention checklist.
Read the guide →Claim Denial Codes Explained: What CO-16, CO-50, CO-197, PR-1 and Others Mean and How to Fix Them
What common denial codes mean (CO-16, CO-18, CO-50, CO-97, CO-197, PR-1 and more) and how to fix each, for mental health and medical practices.
Read the guide →Medical Billing Services for Small Practices: Complete Guide to Maximizing Revenue
Explore medical billing services for small practices, from claim submission and payment posting to denial follow-up, with practical steps to improve revenue.
Read the guide →Find out what your claims are leaving on the table
Tell us about your practice. We will review 90 days of claims and show you what is recoverable, at no cost.
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