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The 5 Most Challenging Procedures for Optometrists and How to Maximize Insurance Reimbursement
- CRC
- Feb 3
- 4 min read
Optometry is a complex field that requires both technical skill and in-depth knowledge of insurance billing practices. While many procedures are straightforward, some require a high level of expertise and precision. Additionally, proper billing and coding are essential to ensure maximum reimbursement from insurance providers.
1. Specialty Contact Lens Fitting (Scleral & Hybrid Lenses)
Why It’s Challenging:
Fitting specialty contact lenses, such as scleral and hybrid lenses, requires advanced training, expensive diagnostic lenses, and additional chair time. These lenses are often used for patients with keratoconus, severe dry eye, or post-surgical corneas, making the fitting process complex and time-intensive.
Billing for Maximum Reimbursement:
Use Proper CPT Codes:
92313 – Fitting of contact lens for corneal disease (for scleral lenses).
92072 – Fitting of contact lens for keratoconus.
92310 – Contact lens fitting for other than aphakia (for hybrid lenses).
Include a Diagnosis Code: Always pair the CPT codes with a medically necessary diagnosis, such as:
H18.601 – Keratoconus, right eye.
H18.602 – Keratoconus, left eye.
H16.221 – Keratitis, right eye.
Verify Coverage: Many insurers consider specialty lenses medically necessary, so pre-authorization may be required.
2. Amniotic Membrane Placement for Ocular Surface Disease
Why It’s Challenging:
Amniotic membrane therapy is used for severe dry eye, recurrent corneal erosions, and neurotrophic keratitis. Proper placement and handling require precision, and reimbursement can be tricky if not billed correctly.
Billing for Maximum Reimbursement:
CPT Code:
65778 – Placement of amniotic membrane (self-retaining).
65779 – Placement of amniotic membrane (sutured).
Diagnosis Codes to Use:
H16.221 – Keratitis, right eye.
H16.222 – Keratitis, left eye.
H04.123 – Dry eye syndrome.
Key Billing Tips:
Ensure the procedure is medically necessary and documented properly.
Some insurers may require prior authorization before coverage is approved.
Bill separately for an evaluation and management (E/M) visit if a full exam is conducted on the same day.
3. Punctal Plug Insertion for Dry Eye Management
Why It’s Challenging:
Although inserting punctal plugs is a relatively quick procedure, many optometrists face challenges with insurance reimbursement due to improper documentation or bundling issues.
Billing for Maximum Reimbursement:
CPT Codes:
68761 – Closure of lacrimal punctum by plug, each.
Diagnosis Codes to Use:
H04.123 – Dry eye syndrome.
M35.01 – Sjögren’s syndrome with keratoconjunctivitis sicca.
Billing Strategies:
If plugs are inserted in both eyes, bill 68761 with modifier -50 (bilateral procedure) to maximize reimbursement.
Some insurers may bundle this procedure with an office visit; ensure proper documentation justifying a separate charge.
Consider using an Advance Beneficiary Notice (ABN) if there is uncertainty regarding coverage.
4. Optical Coherence Tomography (OCT) for Retinal and Glaucoma Management
Why It’s Challenging:
OCT is a crucial tool for diagnosing and managing glaucoma, diabetic retinopathy, and macular degeneration. However, some insurers may deny reimbursement if the exam is not justified with a proper diagnosis code.
Billing for Maximum Reimbursement:
CPT Codes:
92133 – OCT of optic nerve for glaucoma.
92134 – OCT of retina for macular conditions.
Diagnosis Codes to Use:
H40.11X1 – Primary open-angle glaucoma, mild stage.
H35.31 – Nonexudative macular degeneration.
E11.329 – Mild nonproliferative diabetic retinopathy.
Important Notes:
Medicare and many private insurers cover OCT once per year per eye condition unless progression is noted.
Ensure documentation includes clinical findings and justification for frequent testing.
Some payers require modifiers (e.g., -RT for right eye, -LT for left eye) if billing for unilateral conditions.
5. Myopia Management with Orthokeratology (Ortho-K)
Why It’s Challenging:
Orthokeratology (Ortho-K) is becoming increasingly popular for controlling myopia progression in children, but many insurance plans do not cover it, making reimbursement difficult.
Billing for Maximum Reimbursement:
CPT Code:
92310 – Contact lens fitting for other than aphakia (used for Ortho-K lenses).
92071 – Fitting of contact lens for treatment of ocular surface disease (if necessary).
Diagnosis Codes to Use:
H52.13 – Myopia, bilateral.
Z01.00 – Encounter for examination of eyes and vision without abnormal findings.
Billing Strategies:
Most insurance plans do not cover Ortho-K as it is considered elective; therefore, optometrists should offer cash-pay options and use written financial agreements.
If treating a patient with progressive myopia, some vision plans may provide partial reimbursement for medically necessary contact lens fittings.
Always document the necessity of Ortho-K in preventing high myopia to support any potential appeals for coverage.
Final Thoughts: Maximizing Reimbursements in Optometry
Proper billing and coding are critical for ensuring fair compensation for optometric services. To optimize reimbursement:
✅ Verify insurance coverage and obtain pre-authorizations when required.
✅ Use the correct CPT codes and pair them with the appropriate ICD-10 diagnosis codes.
✅ Apply modifiers correctly, especially for bilateral procedures.
✅ Document medical necessity thoroughly to justify claims.
✅ Educate patients on out-of-pocket costs for services that may not be covered.
By mastering both the clinical and financial aspects of these challenging procedures, optometrists can provide top-tier care while ensuring their practice remains financially sustainable.
🔎 Do you have questions about optometry billing and coding? Share your thoughts below! ⬇️
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