ASC Ophthalmology Billing

Ophthalmology is one of the largest ASC specialties with 15% of surgery center procedures classified as ophthalmology (per the ASC Association). Furthermore, many single-specialty centers are ophthalmology -specific. Since 2008, most retinal procedures have been on Medicare’s approved list for ASC’s and commercial payers have followed suit. Coupled with advances in technology, the result has been continued growth in ASC ophthalmology procedures. Plus patients are attracted to the “friendly” outpatient environment of an ASC versus the hospital alternative.

Skills required for ASC Ophthalmology Billing

Billing for ASC ophthalmology procedures can be complex. Ophthalmology represents a wide variety of procedures (some examples are listed below) and underlying causes (diagnoses). Payer rules are not consistent and can be confusing. As a result, it is recommended that centers employ only experienced ophthalmology coding and billing staff. Billing staff must be knowledgeable in coding, charge posting, claims filing, payment posting, customer service, A/R follow-up including denial management, and reporting.

Many centers find attracting and retaining these skills in a relatively small staff to be a challenge. For this reason, hiring a firm who specializes in ASC ophthalmology billing may be the best option. The right firm offers an ASC the ability to hire a team of experts, specialized and skilled in each of the billing disciplines, while only paying for a fraction of the costs. Since a professional ASC billing company performs coding and billing for many ASC’s, economies of scale are realized and passed along to clients. The volume of work justifies having specialists and experts and avoids the risk that an ASC faces with internal staffing: “jack of all trades, but master of none.�

For more ophthalmology billing information, call toll-free 877-501-1611 or fill in the form.

ASC Ophthalmology Billing Considerations

“Days in A/R” is always an important metric. Studies have suggested a national average for ophthalmology surgery centers of over 50 days. In contrast, high performing centers (including AHS clients), typically see average days in A/R in the mid-thirties. This represents a significant one-time cashflow improvement and ongoing acceleration of income.

Patient billing often affects A/R and billing results for ophthalmology ASCs. Patients can be surprised by the size of their bills (many do not realize that they will receive separate facility and physician bills along with an anesthesia bill and the average ophthalmology charge is over $4300 per case according to VMG Health, LLC), and confused by payor reimbursement explanations. Billing staff and procedures designed to minimize these roadblocks can be much more successful in collecting patient balances in a timely manner. For example, patient education in advance about insurance reimbursement procedures and amounts has proven to be highly effective for some centers.

Insurance underpayments are an issue for all specialties, but they can be particularly troublesome for ophthalmology ASCs given the relatively thin margins. Underpayments can represent 10% or more of a ophthalmology surgery center’s revenue.

As everyone knows, ophthalmology coding rules are constantly changing. Careful coding of “routine” ophthalmology procedures is very important. At its most basic level, this means coders must carefully review the operative note and assure they’ve accurately and completely captured exactly what was done. For example, distinguishing between complex and routine cataract surgery. While the Medicare ASC facility reimbursement rate is the same, this is not true for the physician’s professional reimbursement. Since complex cases represent only 6% of cases, they can easily be mis-coded, resulting in an underpayment. Furthermore, some commercial payers will separately reimburse centers for supplies used in complex cases such as capsular tension rings, iris hooks, eyelid weights, etc. If they are properly recorded in the operative note and coded.

Selected ASC Ophthalmology Procedures

Is your ASC performing many or most of these procedures? Or the hundreds of others performed in centers across the country? Are you confident that you are being fully reimbursed? If not, ask us about a free surgery center financial analysis.

Trabeculoplasty (65855)
Retina repair, photocoagulation (67105)
Prophylaxis of retinal detachment, photocoagulation (67145)
Destruction of retinal lesions, photocoagulation (67210)
Destruction of retinal lesions, photodynamic therapy (67221)
Destruction of extensive or progressive retinopathy, photocoagulation (67228)
Injection of vitreous substitute, pars plana or limbal approach, fluid-gas exchange, with or without aspiration, separate proce dure (67025)
Intravitreal injection of a pharmacologic agent, separate procedure (67028)