Medical versus vision plan
A routine refraction goes to the vision plan; a medical complaint or diagnosis goes to the medical plan. The reason for the visit — not the provider type — decides, and billing the wrong plan denies or underpays.
Specialties › Optometry & Ophthalmology
Optometry & Ophthalmology Medical Billing Services
Eye care has a payer problem no other specialty shares: the same patient can be billed to a vision plan or a medical plan depending on why they came in, and choosing wrong means either a denial or leaving the higher-paying claim unbilled. Add the choice between eye-specific exam codes and standard E/M, plus diagnostic imaging that carries its own frequency rules, and optometry revenue turns on billing decisions made before a claim is ever coded.
What makes it hard
Optometry & Ophthalmology billing challenges we solve
These are the issues that repeat every month in optometry & ophthalmology practices — and the ones we fix at the source rather than reworking claim by claim.
Eye codes versus E/M
Ophthalmological service codes and standard evaluation and management codes are alternatives with different requirements. Choosing the more appropriate and better-supported option affects both payment and audit risk.
Refraction billing
Refraction is separately billable and frequently non-covered by medical plans, so it must be handled as its own line with the correct patient responsibility rather than absorbed or written off.
Diagnostic imaging frequency
OCT, visual fields and fundus photography have frequency limits and medical necessity requirements tied to the diagnosis. Repeat imaging outside the interval denies.
Same-day service rules
A medical exam and a vision service on the same day, or an exam plus a minor procedure, require correct modifiers to be separately payable.
Coding depth
Common code families we work with
- 92002 / 92004 / 92012 / 92014 — ophthalmological services, new and established
- 92015 — determination of refractive state (refraction)
- 92133 / 92134 — OCT of the optic nerve and retina
- 92083 — visual field examination
- 92250 — fundus photography
- 99202–99215 — evaluation and management (alternative to eye codes)
- Modifier use for same-day medical and vision services
Listed for context only — this is not billing advice, and payer policy varies. Our certified coders work to AAPC and AHIMA standards.
Denial prevention
Top denial drivers in optometry & ophthalmology
- Claim sent to the wrong plan type (medical vs vision)
- Refraction billed as covered when the plan excludes it
- Imaging repeated inside a frequency limit
- Eye code and E/M mismatched to documentation
- Same-day services billed without a distinguishing modifier
We root-cause denials by payer and procedure, then fix the upstream workflow so the same denial stops recurring.
Why ERG
What you get with ERG
Specialty-trained billers
Your account is worked by people who bill optometry & ophthalmology every day — not a general pool learning your rules on your claims.
95%+ net collection rate
Relentless follow-up on every claim, with aged A/R worked rather than written off.
No long-term contract
Performance-based pricing — a percentage of what we collect. Stay because the results are good, not because you are locked in.
5–10 day onboarding
We run parallel with your current process until the transition is verifiably clean.
Human-led, AI-supported
Our certified coders work every claim; AI tools help them catch more before submission.
HIPAA-compliant throughout
Strict PHI controls, access limits and staff training across the whole workflow.
FAQ
Optometry & Ophthalmology billing — common questions
How do you decide medical versus vision plan?
By the reason for the visit and the diagnosis. A medical complaint or finding is billed medically; a routine vision exam goes to the vision plan. This single decision is where most optometry revenue is won or lost, and we make it deliberately rather than defaulting.
Do you bill both optometry and ophthalmology?
Yes. We bill routine and medical eye care, diagnostic imaging and in-office procedures, applying the correct code family and plan for each encounter.
How do you handle refraction?
As its own separately billable service with the correct patient responsibility, since many medical plans do not cover it. That keeps it from being written off or improperly bundled.
Can you reduce our imaging denials?
Yes. OCT and visual field denials usually trace to frequency limits or diagnosis linkage. Our A/R analysis identifies the pattern so imaging is billed when it is actually payable.
Client results
What practices say about working with us
★★★★★The transition from our old system was handled cleanly — no gap in revenue, no lost claims.
— Susan B., Office Manager
★★★★★Our A/R days dropped from 58 to 31 in one quarter. First time in years I actually trust my numbers.
— Sarah M., Practice Manager
Next step
See what your optometry & ophthalmology practice is leaving uncollected
A no-obligation A/R analysis. We review your aging, denial patterns and coding mix, then show you exactly where the recoverable revenue is.
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