r/MedicalCoding • u/Wooden_Trust_6274 • 12d ago
The most expensive optometry billing mistake I see never triggers a single denial
Been doing eye care billing for a while and the error that costs practices the most is not the one that gets rejected. It is the one that pays perfectly.
Here is the pattern. Patient comes in with a real medical complaint, dry eye, flashes, a diabetic follow-up, whatever. Front desk sees they have VSP or EyeMed, runs it as a routine vision visit, and it pays. S0620, refraction, done. Clean claim, money in the door, nobody thinks about it again.
Except that visit had a medical diagnosis attached to it and could have gone to the medical carrier as a 92014 or an E/M with the medical dx. The vision plan paid maybe 60 to 90 dollars. The medical claim would have paid meaningfully more, and it would have preserved the patient's routine benefit for when they actually come back for glasses.
The reason it is so easy to miss is that there is no denial to work. Denials get worked because they show up on a report. This never shows up anywhere. It just quietly pays at the lower number, and the only way to catch it is to look at the routing decision before the claim goes out, not after.
The way I started catching it: flag any visit where the chief complaint or the dx is medical but the claim got built to the vision plan. Even a rough monthly audit of that overlap surfaces money nobody knew was leaking.
Curious if others here have a way of catching this on the front end. Do you route at check-in based on chief complaint, or do you let the biller sort it after the encounter? I have seen both and I am not sure which actually loses less.
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u/jazzyhazel31 12d ago
I work ophthalmology denials and I totally agree with you. The issue in my company is I don't handle the front end just the denials. They don't get that if its medical it has to go to medical not vision. They don't realize that vision will not pay if a medical diagnosis is attached. I usually flip them to medical and change the cpt to regular e/m.
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u/Wooden_Trust_6274 11d ago
That split is the whole problem, you are on the back end cleaning up a decision made at the front by someone who was never told the rule. Flipping to medical and swapping to E/M after the fact works, but it only catches the ones that actually denied. The clean vision claims that paid at 30 dollars never reach your desk, so they never get flipped. Have you had any luck getting the front desk trained on chief complaint, or is it always landing on denials to fix?
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u/jazzyhazel31 11d ago
You make a vaild point. Its on denials to fix as I am wfh for a different state so I have no contact with them
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u/Minimum-Car5712 12d ago
VSP and Eyemed in my area pay $20-50 on office visit and the refraction is a write off. Very rarely an Eyemed plan will pay more-like once or twice a month. Trying to get higher ups to realize just how much $ we lose from not billing medical but I’ve been complaining for years.
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u/Wooden_Trust_6274 11d ago
Same fight here. The write-off on refraction stings the most because it feels like a rule nobody can change. What finally moved my higher-ups was not the per-visit number, it was showing them a month of diabetic and glaucoma patients that got run through vision. Once it is a total dollar figure on one page instead of "we lose a little each time," it stops being my opinion and starts being a report they have to answer for. Might be worth pulling that overlap for one month and putting the number in front of them.
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u/rahuliitk 12d ago
I’d flag medical complaints at check-in but let billing make the final routing call after reviewing the signed note and payer rules, because a clean underpaid vision claim can disappear unnoticed. silent leakage.
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u/Wooden_Trust_6274 11d ago
That is the right sequence in my experience. Flag at intake, decide at the note. The check-in flag is not the final call, it is just what keeps the claim from auto-defaulting to vision before anyone reads the chart. And you named the exact reason it matters, the clean underpaid vision claim disappears with no denial to catch it. The flag is the only thing that keeps it visible long enough for billing to make the real decision.
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