Optometry billing services
Optometry practices bill vision plans and medical plans, sometimes for the same patient on the same day. We keep both sides accurate so neither leaves money behind.
Why optometry billing takes specialty knowledge
Optometry billing runs on two tracks. Routine eye exams, glasses and contact lenses go to vision plans like VSP, EyeMed and Davis Vision. Medical eye care, such as dry eye, glaucoma monitoring, diabetic eye exams and foreign body removal, goes to Medicare, Medicaid and commercial medical plans. Choosing the wrong track at check-in is the most common reason optometry claims are denied or paid at the wrong rate.
SFA Solutions verifies both vision and medical benefits before the visit, so your front desk knows which plan to bill based on the reason for the visit. Our coders handle eye codes and E/M codes, refraction, contact lens fitting and the diagnostic tests that optometrists perform every day. We work inside your current EHR and practice management system and aim to submit most clean claims within 24 hours of final review.
Common codes we work with in optometry
| Code | Description |
|---|---|
| 92004 | Comprehensive ophthalmological exam, new patient |
| 92014 | Comprehensive ophthalmological exam, established patient |
| 92015 | Determination of refractive state (refraction) |
| 92310 | Prescription and fitting of contact lenses, corneal lens, both eyes (except for aphakia) |
| 92250 | Fundus photography with interpretation and report |
| 92083 | Visual field examination, extended, unilateral or bilateral |
| 65222 | Removal of foreign body, external eye, corneal, with slit lamp |
| 68761 | Closure of the lacrimal punctum by plug, each |
CPT is a registered trademark of the American Medical Association. Payer rules vary; we check each payer's current policy.
Where optometry practices lose revenue
Vision plan versus medical plan
The chief complaint and diagnoses drive which plan is billed. A patient who comes in for blurry vision and new glasses is a vision plan visit, while a patient being followed for glaucoma or diabetic retinopathy is a medical visit. Some vision plans also cover limited medical services, and their rules need checking.
Refraction and contact lens fitting
Refraction (92015) is non-covered by Medicare and many medical plans, so it is collected from the patient or billed to a vision plan. Contact lens fitting codes like 92310 are usually not covered by medical plans except for specific conditions such as keratoconus. Clear financial policies prevent write-offs.
Medical testing and procedures
OCT (92133 or 92134), visual fields (92083), fundus photography (92250) and procedures like corneal foreign body removal (65222) and punctal plugs (68761) are billable to medical plans with supporting diagnoses. Testing frequency limits and NCCI pairing edits apply.
Diabetic eye exams and quality codes
Diabetic eye exams are billed to the medical plan, and CPT Category II codes such as 2022F and 2023F report whether retinopathy was found. Health plans use these for quality measures, and reporting them helps the patient's primary care practice close care gaps.
What else affects optometry revenue
A/R challenges in optometry
Optometry A/R splits between vision plan claims that pay at fixed rates and medical claims that take longer and deny more often. Materials claims for frames, lenses and contacts depend on matching the plan's authorization, and a mismatch or expired authorization holds up payment. Patient balances for contact lens fittings and lens upgrades are best collected at checkout, before they age.
Credentialing considerations
Optometrists need separate credentialing with vision plans such as VSP, EyeMed, Davis Vision and UnitedHealthcare Vision, and with medical plans including Medicare and Medicaid. Some medical plans and IPAs limit which eye care providers they add to the panel, so applications can take longer. Every office location must be listed with each plan, and scope of practice for procedures and prescribing varies by state.
Payer considerations
Original Medicare does not cover routine refractions or glasses, with one exception: one pair of eyeglasses or contact lenses after cataract surgery with an intraocular lens. When a patient has both vision and medical coverage, the reason for the visit decides which plan is billed for the exam. Some medical plans also carve out eye care to a separate administrator, so eligibility checks need to confirm where medical eye claims go.
Optometry coding details that affect payment
ICD-10 considerations
The diagnosis decides which plan pays. Routine vision visits use Z01.00 or Z01.01 (encounter for examination of eyes and vision) and refractive error codes such as H52.13 (myopia, bilateral), which medical plans generally do not cover. Medical visits need specific codes with laterality, such as H04.123 for dry eye syndrome of both eyes, H40.013 for open angle glaucoma suspect with borderline findings, low risk, bilateral, or T15.01XA for a foreign body in the cornea of the right eye. Diabetic eye exams with no retinopathy are coded with the diabetes code, such as E11.9, while retinopathy uses the E11.3 combination codes, and keratoconus (H18.6 codes) supports medically necessary contact lens fitting.
Modifiers to watch
| E1 to E4 | Used on punctal plug claims to identify which eyelid's punctum was treated. |
|---|---|
| RT and LT | Applied to unilateral procedures such as foreign body removal so the claim matches the eye in the diagnosis. |
| 25 | Added to the exam when a separate, significant problem is evaluated on the same day as a minor procedure like foreign body removal. |
| 55 | Used by the optometrist who provides postoperative care after cataract surgery under a co-management agreement with the surgeon. |
| KX | Required under the DME MAC refractive lens policy on post-cataract eyeglass or contact lens claims when the coverage criteria are met. |
Global periods
Corneal foreign body removal (65222) carries a 0-day global and punctal plug insertion (68761) a 10-day global, so a recheck for the same problem within 10 days of plugs is included. When an optometrist co-manages cataract patients, the postoperative portion billed with modifier 55 is limited to the dates of care after the transfer.
Medicare considerations
Medicare's one pair of eyeglasses or contact lenses after cataract surgery is billed to the DME MAC with V-codes, which requires the practice to be enrolled as a DMEPOS supplier. Medicare covers annual glaucoma screening for high-risk patients with G0117 or G0118, while medical eye visits for conditions such as dry eye or glaucoma follow regular Part B rules.
Optometry billing KPIs to track
- Medical versus vision visit mix. Tracking the share of medical visits shows whether medical eye care is being identified and billed to the right plan.
- Materials claim rejection rate. Frames, lenses and contacts claims that do not match the vision plan's authorization hold up payment.
- Medical claim denial rate. Medical claims deny more often than vision claims, so this rate shows where diagnosis coding or eligibility needs work.
- Patient collections at checkout. Refraction, fittings and lens upgrades are patient balances that are easiest to collect before the patient leaves.
Optometry billing audit checklist
- Confirm each visit was billed to the vision or medical plan that matches the chief complaint and diagnoses.
- Check that refraction is collected from the patient or billed to the vision plan, not left open on a medical claim.
- Verify diabetic eye exams include the correct diabetes code and Category II retinopathy codes.
- Review punctal plug and foreign body claims for eyelid or eye modifiers matching the diagnosis.
- Confirm contact lens fittings billed to medical plans have a qualifying diagnosis such as keratoconus.
- Check that every office location is listed with each vision and medical plan.
Related: Optometry coding · denial management · RCM · billing audit · Optometry billing in Texas · Epic billing · athenahealth billing · RCM resources
How SFA runs optometry billing
We review your payer list and benefit verification process to see where vision and medical claims are being crossed.
Before each visit we verify vision and medical coverage and note what the patient will owe for refraction or contact lenses.
Coders assign eye or E/M codes, tests and procedures to the correct plan, with a 24-hour target for submitting clean claims after final review.
We follow up on denials and underpayments from both vision plans and medical payers and report results monthly.
The services that matter most for optometry
Eligibility Verification & Prior Authorization
Checking vision and medical benefits before the visit decides which plan is billed and what the patient owes.
Learn moreMedical Billing
Clean submission to both vision plan portals and medical payers keeps both revenue streams moving.
Learn moreCredentialing & Payer Enrollment
Optometrists need separate enrollment with vision networks and medical payers, and missing either one blocks payment.
Learn moreWhat practices typically see with SFA
Averages and selected client results. Your free audit shows where your own numbers stand today.
Target for the claims we manage, not a measured average.
Highest improvement seen in selected client results.
Largest drop in A/R days seen in selected client results.
Targeted for submission within 24 hours after final review.
From primary care and nurse practitioners to surgery and imaging.
We work inside the system your practice already uses.
Results vary by practice, specialty, payer mix, claim volume, billing history, documentation and other factors. Performance figures represent average or selected client results and are not guarantees of future performance. The 95% figure is a clean-claim target, not a measured cohort. The client-results page does not include a measurement period, starting collections, or practice size.
Optometry billing questions
Can one visit be billed to both a vision plan and a medical plan?
Generally, one exam is billed to one plan based on the primary reason for the visit. Some practices split services, such as billing the exam to medical and refraction to the vision plan, but only when the vision plan allows it.
Does Medicare cover routine eye exams?
No. Medicare covers medically necessary eye care and certain screenings, such as an annual dilated exam for patients with diabetes and glaucoma screening for high-risk patients. Routine exams for glasses are not covered.
How do you bill for dry eye treatment?
Dry eye visits are billed to the medical plan with the appropriate diagnosis. Procedures like punctal plug insertion (68761) are billed per punctum with eyelid modifiers, and some in-office treatments are non-covered and billed to the patient.
Can optometrists bill Medicare as physicians?
Yes. Optometrists are recognized as physicians under Medicare for services within their state scope of practice, and they enroll and bill under their own NPI.
Do you handle credentialing with vision plans?
Yes. Credentialing is included free with every billing plan, and we handle enrollment with both vision networks and medical payers.
See what your optometry billing is missing
Send us a few details and an RCM specialist who knows optometry will review where claims are denied, underpaid or left unbilled.
- A clear walkthrough of what we find
- Reply typically within one business day
- No commitment
Request your free practice audit
An RCM specialist typically replies within one business day.