Specialty
Optometry billing services
Optometry billing services sort every visit into the benefit that pays for it: a routine exam and refraction belong to the vision plan or the patient, a medical eye problem belongs to the medical plan, and Medicare pays an eye exam only when a medical diagnosis drives it.
See where claims are getting stuck. No patient data needed.
Remitwright gives optometry practices a dedicated biller who checks both the vision and the medical eligibility before the visit, matches the eye exam or E/M code to the chart, carries RT and LT, modifier 55 and the eyewear V-codes the way each payer processes them, and works every refraction, frequency and co-management denial back to its cause.
Optometry billing is one of Remitwright's specialty billing services, each set out with its own code families, denial reasons and payer rules.
Last reviewed by the Remitwright billing team. Editorial policy
- 65205-65222
- 92002-92014
- 92015
Denials
Why optometry claims get denied
The reasons that come up most on optometry remittances, with the usual cause and the fix. Code explanations are our own; the official list is maintained by X12.
| Code | Reason | Usual cause | The fix |
|---|---|---|---|
| CO-96 | Non-covered service | A refraction or a routine exam for glasses billed to Medicare or to a medical plan that excludes routine vision, or a lens upgrade billed as covered | Routine work identified at scheduling, the refraction kept as its own line, the exclusion flagged with GY where the denial is wanted, and the vision plan or the patient billed directly |
| CO-109 | Claim not covered by this payer | A routine exam or eyewear sent to the medical plan when the routine benefit sits with a vision plan, or a Medicaid managed care member whose vision benefit runs through the plan's vendor | Vision and medical eligibility both checked before the visit, with the routine benefit's payer ID, allowance and frequency recorded on the appointment |
| CO-151 | Frequency or units exceed what the payer allows | An exam or a pair of glasses inside a Medicaid frequency window, a glaucoma screening inside its interval, or optical coherence tomography beyond the coverage policy's frequency | Benefit limits pulled from the eligibility response or portal before the service, last-service dates tracked per patient and per eye, and the note's medical necessity used where the policy allows exceptions |
| CO-97 | Bundled, not separately payable | An eye exam code billed with an E/M on the same day, fundus photography billed with retinal OCT, exam components or contact lens follow-ups billed as separate lines | One visit code per day, NCCI edits run before release, and 59 or XU on photography only when the record shows a condition that needed both techniques |
| CO-50 | Not medically necessary | Visual fields, OCT or photography billed with a refractive or routine diagnosis, or a test whose indication is not in the contractor's coverage policy | The medical diagnosis linked to each test, the policy's covered indications loaded into the coding checklist, and the order and interpretation in the chart |
| CO-4 | Procedure inconsistent with the modifier | RT or LT missing on a unilateral code, 55 billed with the post-op visit date instead of the surgery date, or 25 missing on the exam billed with punctal plugs | Modifier rules by payer built into charge entry, co-management claims checked against the surgeon's date and code, and corrected claims sent as replacements |
| CO-B7 | Provider not eligible on this date | An optometrist not enrolled with the medical plan or Medicare, or a code outside the specialty's allowed code set under a state Medicaid program | Enrollment and revalidation tracked per plan with effective dates, and each state's optometry code set checked before a new service is added |
Codes
Common optometry codes and modifiers
Code families by number with our own one-line explanations. CPT descriptors belong to the AMA and are not reproduced here.
| Codes | What the family covers |
|---|---|
| 65205-65222, 68761, 68801 | Minor office procedures within optometric scope: removal of a foreign body from the conjunctiva or cornea, punctal plugs and dilation of the lacrimal punctum. Each carries a short global period and a side. |
| 92002-92014 | The general eye exam codes for new and established patients at two levels, reported instead of an E/M code for the visit. The parts inside them, history, acuity, external exam, ophthalmoscopy, tonometry and gross fields, are not billed as separate lines. |
| 92015 | Refraction, the measurement that produces the spectacle prescription and specifies the lens. Medicare does not cover it, so it is billed to the vision plan or to the patient and kept as its own line. |
| 92081-92083, 92133, 92134, 92250, 92285 | Special testing that stands apart from the exam: visual fields by extent, optical coherence tomography of the optic nerve or the retina, fundus photography and external photography. Each needs a medical reason and runs into payer frequency limits. |
| 92310-92326, 92071, 92072 | Contact lens prescription and fitting, including the bandage lens for ocular surface disease and the fitting for keratoconus. Instruction, training and follow-up during the fitting period are inside these codes. |
| 99202-99215 | Office visits leveled by medical decision making or time, the alternative to the eye exam codes when a medical problem or counseling drives the visit. A payer sees one visit code per day, never both. |
| G0117, G0118 | Medicare glaucoma screening for patients in a high-risk group, performed by or under the supervision of an eye doctor, with a once-per-period limit the practice tracks per patient. |
| V2020-V2799 | Eyewear HCPCS: frames, single vision, bifocal and progressive lenses, tints, coatings and polycarbonate, billed per lens or per frame with the day the glasses were dispensed as the date of service. |
Modifiers that matter
- RT and LT
- On every unilateral test, procedure or lens line. Eyes are paired organs, so most edits allow both codes when the work was on opposite sides. A bilateral diagnostic test goes on one line with 50 or on two lines with RT and LT, depending on the payer.
- 55
- On the surgical code when the optometrist takes over post-operative care after cataract surgery: the same procedure code and the surgery date the surgeon used, the date care was assumed in the claim remarks, a written transfer agreement in the chart, and a first post-op visit before the claim goes out.
- 25
- On the visit code billed with a same-day minor procedure such as foreign body removal or punctal plugs, when the visit did more than decide to do the procedure. A different diagnosis is not required; a separate paragraph in the note is.
- 24
- On a visit during a global period for a problem unrelated to the surgery that period belongs to, with documentation that shows the problem is not post-operative care.
- GY
- On a refraction or routine exam line sent to Medicare on purpose, so the statutory exclusion is denied quickly and the balance can move to a secondary plan or the patient.
- U8, SC and state eyewear modifiers
- On replacement lenses or frames billed before a Medicaid frequency limit has run. Indiana uses U8 for loss, theft or damage beyond repair and SC for a prescription change, and tint modifiers on the lens add-on code. Each state publishes its own set.
Payers
Payer notes
- Medicare (routine vision)Medicare does not cover routine eye exams, sometimes called eye refractions, for eyeglasses or contact lenses; the patient pays all costs. Some Medicare Advantage plans add vision benefits that Original Medicare does not have, so the plan's routine benefit is checked separately.1
- Medicare (glaucoma screening)Part B covers a glaucoma test once every 12 months for people at high risk: diabetes, a family history of glaucoma, African Americans 50 or older, and Hispanic Americans 65 or older. An eye doctor legally allowed to do glaucoma tests in the state must do or supervise the screening. The patient pays 20 percent after the Part B deductible, plus a copayment in a hospital outpatient setting.2
- Medicare (diabetic eye exam)An eye exam to check for diabetic retinopathy is covered once a year for a patient with diabetes, performed by an eye doctor legally allowed to do the test in the state, with 20 percent coinsurance after the deductible.3
- Medicare (eyewear after cataract surgery)Part B covers one pair of eyeglasses with standard frames, or one set of contact lenses, after each cataract surgery that implants an intraocular lens. The patient pays 20 percent after the deductible plus any cost of upgraded frames, and Medicare pays only a supplier that participates in Medicare, whether the patient or the provider submits the claim.4
- Medicare (optometrists and prosthetic lenses)Since April 1, 1987 a doctor of optometry has been a physician for every service the optometrist may perform under state law, provided the service is reasonable and necessary. The prosthetic lens benefit allows one pair of conventional eyeglasses or contact lenses after each cataract surgery with an intraocular lens, and cataract sunglasses obtained in addition to the regular lenses are not covered.5
- Medicare (co-management of surgery)When the surgeon transfers post-operative care, the surgeon bills the procedure with 54 and the provider who manages recovery bills the same procedure code with 55, both with the date of surgery as the date of service. Both keep a copy of the written transfer agreement in the record, the receiving provider must furnish at least one service before billing, and split billing does not apply to codes with a 0-day post-operative period. A 10-day global runs 11 days counting the surgery day; a 90-day global runs 92 days including the day before surgery.6
- Medicare (claims processing)The claim does not need to state that care was transferred, but the date on which care was relinquished or assumed must appear in the remarks or free-text segment. The receiving physician cannot bill any part of the global package until the first service, and then bills from the date care was assumed.7
- Medicare and plans that apply NCCIThe general eye exam codes are components of the ophthalmologic examination and are not reported with an E/M code, which includes them. Special ophthalmological services are separately reportable. Fundus photography and scanning ophthalmic imaging are generally mutually exclusive on the same eye, with both reportable only in a limited set of conditions and 59 or XU on the photography code. The bandage lens fitting code is not reported with a corneal procedure for a lens applied at the end of that procedure.8
- Medicare (SCODI LCD, First Coast)Posterior segment OCT is covered for glaucoma management, for conditions of the optic nerve or retina, and for monitoring chloroquine or hydroxychloroquine. Frequency is limited to two exams a year for glaucoma and for anterior segment imaging, one exam every two months for retinal disease not under active treatment, one a month under active treatment, and one a year for drug monitoring. Screening a patient without signs or symptoms is not covered, and the record must hold the results, the comparison with prior tests and the analysis.9
- Medicare (SCODI LCD, WPS)The WPS version of the policy expects usually one or two tests a year for glaucoma, no more than one exam per eye every two months for retinal disease, and one scan a month per eye during intravitreal treatment, with the record documenting the history, examination and results that support each test. Each contractor publishes its own version, so the frequency your region applies is the one to load.10
- Medicaid (Indiana, as an example of state rules)Indiana Medicaid covers an eye exam once per 12 months under age 21 and once every two years at 21 and older, and eyeglasses once per 12 months under 21 and once every five years at 21 and older, only when a minimum prescription or change is met. Most vision services need no prior authorization, but blepharoplasty, prosthetic devices other than eyeglasses and reconstructive surgery do. Benefit limits are checked through the eligibility system or the 270/271 transaction, managed care members follow their plan's rules, optometrists bill only from their specialty code set, and the date of service for glasses is the day they were dispensed.11
- All payers that apply NCCI editsProcedure-to-procedure edits for paired organs such as the eyes generally allow both codes when the work was on opposite sides and not when it was on the same eye. Where a code's bilateral indicator is 1, a bilateral diagnostic test is reported as one unit with 50 on one line, or one unit with RT and one unit with LT on two lines. Units over the medically unlikely edit are denied per line or per date of service.12
Authorizations
Medicare does not ask an optometry practice for prior authorization; it gates payment with coverage rules instead. Routine exams and refractions are excluded by statute, the glaucoma screening and diabetic eye exam carry fixed intervals, and the OCT policies carry frequency limits and covered indications. Vision plans run the routine benefit: the exam, frame and lens allowances and the contact lens benefit are confirmed through the plan before the visit, because the plan's frequency clock, not the chart, decides what it pays. Medical plans rarely require authorization for optometric services, though some ask for it before extended testing or minor surgery. Medicaid programs set benefit limits with authorization for the exceptions, and Indiana's list covers blepharoplasty, prosthetic devices other than eyeglasses, reconstructive surgery and a few injected drugs. Cataract co-management needs a written transfer agreement, not an authorization. Your biller checks both eligibilities, records the limits on the appointment, and keeps the matrix per plan.
Documentation traps
- A chief complaint of "routine exam" or "wants new glasses" on a visit whose tests are billed to the medical plan; the medical reason for the visit and for each test has to be written down
- The refraction folded into the exam fee or missing from the note, so the vision plan's share and the medical plan's share cannot be separated when both are involved
- Visual fields, OCT and photography without an order, an interpretation and a signature; the coverage policies expect results, comparison with prior tests and the analysis in the record
- Co-management without the written transfer agreement, the date care was assumed and a first post-operative visit before the claim with 55 is sent
- Eyewear dispensed on a later date than the exam but billed with the exam date; the date of service for glasses is the day the patient received them
- Contact lens fitting notes without the lens parameters and the follow-ups inside the fitting period, so visits that belong to the fitting are billed separately and denied
- The eye not stated for a unilateral test or procedure, which leaves RT or LT unsupported and a bilateral claim open to a units edit
What a specialist checks
Specialist or generalist for optometry billing?
A generalist biller can enter an optometry claim. Whether it pays turns on three things specific to optometry billing, and a specialty-aware biller checks each one.
Code families
Each family billed with what the chart has to show for it.
- 65205-65222, 68761, 68801
- 92002-92014
- 92015
Modifiers
Applied only where the note supports them, line by line.
- RT and LT
- 55
- 25
If you are moving from another billing company or an in-house biller, switching billing companies follows a plan: the old and new processes run side by side until the new one is proven, and every login and every optometry claim stays in your name.
What we handle
What we handle for optometry practices
- Eligibility verificationCoverage and benefits checked before visits
- Medical codingCPT, ICD-10 and modifiers assigned correctly
- Claim submissionScrubbed, submitted and tracked to acceptance
- Denial managementEvery denial read, worked and appealed
- Patient billing supportStatements, questions and payment plans handled
- A/R follow-upUnpaid claims chased before filing limits
A dedicated biller with named cover, working inside your system and reporting to you on one written page. How it works sets out the five stages.
Software
Systems optometry practices usually run
Your biller works inside your system as a user you create. All the systems we work in.
Questions
Questions about optometry billing
Does Medicare pay for a routine eye exam or a refraction?
No. Medicare excludes routine eye exams and refractions for eyeglasses or contact lenses, and the patient pays the whole charge. Medicare does pay for a medical eye visit, a yearly diabetic eye exam, a glaucoma screening once every 12 months for high-risk patients, and one pair of standard glasses or contacts after each cataract surgery with an implanted lens. A Medicare Advantage plan may add a routine benefit, and that benefit has to be checked with the plan.
How do we decide whether a visit goes to the vision plan or the medical plan?
The chief complaint and the diagnosis decide it, not the test performed. A patient who comes in for glasses and has a healthy eye is a vision plan visit, refraction included. A patient who comes in with a red eye, floaters or a diabetic check is a medical visit, and the exam and any testing go to the medical plan with the medical diagnosis. When one visit holds both, the refraction stays on its own line for the vision plan or the patient and the medical work goes to the medical plan.
Can we bill an eye exam code and an E/M code on the same day?
No. The general eye exam codes describe components of the eye examination, and an E/M service already includes them, so NCCI treats the two as one visit. Choose the code that fits the visit: the eye exam codes when the exam elements drive it, an E/M code when medical decision making or counseling drives it. Special tests such as fields, OCT and photography are separate services and can be reported with either visit code when the record supports them.
How often does Medicare pay for a glaucoma screening or a diabetic eye exam?
A glaucoma screening once every 12 months for a patient with diabetes, a family history of glaucoma, an African American patient 50 or older, or a Hispanic patient 65 or older, done or supervised by an eye doctor licensed for it. A diabetic retinopathy exam once a year for a patient with diabetes. Both carry the Part B deductible and 20 percent coinsurance, and a claim inside the interval denies for frequency.
How does cataract co-management billing work for an optometrist?
The surgeon bills the cataract code with 54 and you bill the same cataract code with 55, both using the date of surgery as the date of service. The claim carries the date you assumed care in the remarks field, both charts hold a copy of the written transfer agreement, and you cannot bill until you have seen the patient at least once. A visit for a problem unrelated to the surgery is billed on its own with the modifier that shows it is unrelated.
Why was our OCT denied as not medically necessary?
Usually one of three reasons. The diagnosis on the claim was refractive or routine rather than a covered indication such as glaucoma, a retinal condition or drug monitoring. The scan fell inside the contractor's frequency limit, which runs about two a year for glaucoma, one every two months for retina not under treatment and one a month under treatment. Or the record lacked the interpretation, the comparison with prior scans and the analysis the policy asks for. Each one is fixable before the next claim.
What does Medicare pay for eyeglasses after cataract surgery?
One pair of eyeglasses with standard frames, or one set of contact lenses, after each cataract surgery that implants an intraocular lens, at 80 percent of the approved amount after the deductible. Upgraded frames, extra pairs and cataract sunglasses on top of the regular lenses are the patient's cost. Medicare pays only a supplier enrolled and participating in Medicare, so the optical dispensary's enrollment is part of the setup.
What do you need from an optometry practice to start?
A signed BAA, a user for your biller in your practice management system, EHR and clearinghouse, your vision plan and medical plan contracts and fee schedules, each doctor's enrollment status with Medicare, Medicaid and the medical plans, your optical dispensary's supplier enrollment, and your current process for checking vision benefits. Bring an aging report and a denial report to the review if you have them.
Next step
See where your optometry claims are getting stuck.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
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- No patient data, no software to buy
- A written reply from a biller, not a sales deck
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- A billing specialist reads your answers and replies by email.
- If a look at real claims makes sense, we agree read-only access under a BAA first.
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While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).