Optical Coherence Tomography (OCT) has become a vital tool in diagnosing and managing retinal conditions, glaucoma, and other eye diseases. But for California optometrists, over-reliance on OCT billing, especially without clear documentation, triggers unwanted payer scrutiny.

OCT Billing: A Common Audit Trigger in California

In recent years, both private insurers and Medi-Cal managed care plans have increased audits related to diagnostic imaging. Why? OCTs are high-frequency, high-cost services—and when they are billed too often or without strong clinical justification, they raise red flags.

Some California optometrists may unknowingly bill OCTs at each visit, especially for patients under glaucoma surveillance or with long-standing macular degeneration. But payers now expect clear documentation of disease progression, new symptoms, or treatment impact to justify repeated scans.

Know the Frequency Limits—and the Payer Nuances

Most carriers in California do not publish hard frequency caps for OCT, but that doesn’t mean anything goes. For example:

• Medicare contractors (Noridian) expect a minimum 3-month interval between scans unless there is documented acute change.
• VSP and Eyemed often reject repeated OCTs billed within the same plan year unless paired with strong clinical notes.
• Medi-Cal Managed Care plans, such as Health Net or LA Care, typically require pre-authorization for repeat testing.

As a California-based optometry billing specialist, Instapay Healthcare Services helps practices interpret each payer’s expectations and avoid denials through proactive coding and documentation audits.

Medical Necessity: More Than a Diagnosis Code

Many optometry practices assume that a diagnosis of glaucoma or AMD alone is enough to justify an OCT. Unfortunately, California payers are asking for more.

Your documentation should answer the following:

• What changed clinically since the last scan?
• How will this OCT influence the treatment plan?
• Is this scan necessary today, or could it be deferred?

We’ve seen numerous audits where the only thing missing was a sentence or two explaining why the test was performed again. That’s all it takes to move a claim from payable to denied—or worse, trigger a repayment request.

Audit-Proofing Your OCT Claims

At Instapay Healthcare Services, we work closely with California optometrists to structure their documentation and billing processes in ways that align with current payer expectations. Our approach includes:

• Real-time eligibility checks to flag when benefits may not cover repeat imaging
• Coding support to ensure accurate CPT/ICD-10 pairing for each clinical scenario
• Pre-audit reviews of documentation before high-cost tests like OCT are billed

Whether you're a solo provider in Fresno or part of a larger group in Los Angeles, our optometry billing in California solutions are tailored to your payer mix and patient population.

Final Thoughts

OCT is an indispensable tool, but using it too frequently—or billing it without the right justification—can put your practice under the microscope. With the right partner in your corner, like Instapay Healthcare Services, you can stay compliant and get paid fairly.

Need help managing diagnostic billing risk? Trust Instapay Healthcare Services, your expert optometry billing service provider in California, to help you bill smarter, not harder.