Optometry Coding & Billing Alert

Published on Sun Aug 09, 2009 PDF

Question: Are insurance companies allowed to reduce our fees for multiple procedures performed during the same session? Should I reduce the fee before sending the claim?

California Subscriber

Answer: Many ophthalmic tests are paid at 100 percent each when the ophthalmologist performs the services bilaterally. The payments are not subject to a reduction. Become aware of what those procedures are and how payers should reimburse for them. Also, keep in mind that you should double a procedure billed with modifier 50 (Bilateral procedure) to indicate both eyes to ensure proper claim processing and payment.

If you need to apply modifier 51 (Multiple procedures) to a surgical code, then you'll be facing multiple-procedure fee reductions. Many payers, including Medicare, follow a reduced fee policy for multiple procedures performed during the same operative session. Generally, the policy looks something like this:

• Procedure 1 is paid at 100 percent of the allowable

• Procedure 2 is paid at 50 percent of the allowable

• Procedure 3 is paid at 25 percent of the allowable (for some payers) and 50 percent of the allowable (for some payers).

Important: Even if the payer follows a multipleprocedure reduction policy, you should not reduce the fee before you send your claim. Let the payer reduce the fee.