How to Stay Compliant with New York State Regulations on Optometry Billing

by admin |January 23, 2025 | 6 comments,

Optometry in New York is on rise. This is the result of increased screen usage in big cities and grown concern for eye care. If you are an optometrist in New York state, you want your practice running smoothly without any hassles. Following state regulations of billing is important for consistent success and sustainability of your optometry practice.

Non-compliance with these rules and regulations result in delayed payments, audit risks, and can cause legal consequences. Understanding and adhering to the guidelines set by the New York State and federal regulations ensures that optometry practices operate smoothly while also having their revenue maximized.

New York State Optometry Billing Regulations: Understanding the Basics

The New York State has set specific billing rules that govern optometry services within the state. These include compliance with the state’s Medicaid, third-party payer policies, and also its federal regulations like the Health Insurance Portability and Accountability Act (HIPAA). The New York Department of Health (DOH), New York State Optometric Association (NYSOA), and other regulatory bodies have issued guidelines that must be followed for optometric billing. Not following these leads to claim denials, rejections, audits, and penalties.

As an optometrists, taking care of the following key elements is of utmost importance:

1. Proper Use of Codes: Using correct ICD-10, CPT, and HCPCS codes when submitting claims
2. Documentation Requirements: Keeping detailed patient records that support the services billed.
3. Medicaid Billing Rules: The New York State Medicaid has specific guidelines for optometry services. It includes those related to covered procedures, and has limitations on certain treatments.

Optometrists in New York are typically allowed to perform the following services:

1. Comprehensive eye exams
2. Refraction tests for glasses and contact lenses
3. Diagnosis and management of conditions like glaucoma, diabetic retinopathy, and macular degeneration

Medicaid and Insurance Coverage for Optometry Services in New York

New York Medicaid and private insurance plans offer coverage for optometry services. However, it is important to know the specific rules for billing under each system.

Medicaid Optometry Billing in New York

New York Medicaid covers a range of optometry services. This includes eye exams, glasses, and contact lenses for eligible patients. Billing Medicaid requires specific codes and adherence to documentation guidelines:

1. Medicaid requires providers to follow strict guidelines that demonstrate medical necessity for the services provided.
2. Providers must use the NY Medicaid Vision Services (VSP) provider guidelines for billing of eyeglasses and contact lenses.s
3. Making sure all services are documented well, with appropriate ICD-10 codes linked to that particular service.

Private Insurance Plans in New York

Most private insurance companies in New York cover optometry services under them. The coverage, however, varies significantly depending on the plan chosen:

1. Eyeglasses and contact lenses: Insurance plans may cover a portion of the cost for eyeglasses and lenses. Providers will have to follow each insurer’s guidelines for pre-authorization and billing.
2. Managed care plans: Many patients in New York are covered by managed care organizations (MCOs). This can complicate billing. Providers need to be prepared to navigate different claim submissions processes and coverage restrictions.

Ways to Stay Compliant in New York State as an Optometry Practice

Use the Correct Billing Codes and Modifier

The most important of all ways to be compliant is by starting to see if the correct billing codes and modifiers are used. Billing codes are the backbone of any medical billing system, including optometry. Using the right ICD-10 and CPT codes reflect the services provided.

Common CPT codes-

1. 92002 – New patient eye exam
2. 92004 – Comprehensive eye exam with a refraction
3. 99213 – Office visit for follow-up care
4. 67028 – Pars plana vitrectomy for retinal conditions

Common ICD-10 codes-

1. H52.13 – Myopia (nearsightedness)
2. H40.9 – Glaucoma, unspecified
3. E11.9 – Type 2 diabetes mellitus without complications, important for billing related to diabetic retinopathy

Stay Updated on Medicare, Medicaid and Insurance Changes

New York Medicare, Medicaid and other insurance carriers frequently revise their billing guidelines. This affects everything in the claim submission process, from reimbursements to the services that are covered. Optometrists must be proactive in monitoring these changes to avoid any future errors.

Optometrists can bill Medicare for services related to eye health. It includes eye exams, diagnostic tests for conditions like glaucoma, cataracts, and diabetic retinopathy. Under Medicare, optometrists are not authorized to perform surgical procedures.

In New York, Medicaid covers eye exams, glasses, and a few diagnostic procedures. Medicaid billing must follow the guidelines set by the New York State Department of Health, abbreviated to NYSDOH. Eye care providers must be enrolled in the Medicaid program to receive reimbursement. Providers should regularly keep a check for updates from the New York Medicaid program.

Documenting Everything Thoroughly

Compliance becomes easier when proper documentation has been done. If any issue arises regarding the billing, accurate and complete documentation will help show that the services were rendered correctly as claimed. Make sure all treatments and procedures are clearly documented- diagnosis, patient history, and test results. See to it that the procedures that you bill for are medically necessary, and supported by patient records. These procedures also should be appropriately coded. Another thing to keep in mind is to take thorough notes. These notes help justify the use of specific codes and services. It comes in handy in the event of an audit.

Avoid Upcoding and Unbundling

Upcoding and unbundling are the most common errors in medical billing. When a higher level of a service code is used to receive a larger reimbursement, it is called upcoding. Unbundling is breaking a single service into multiple codes for maximized payments. Both of these result in several penalties. These practices are fraudulent, and cause significant damage to your professional as well as practice reputation.

Make sure to only bill for the services rendered at an appropriate level. See to it that the correct bundled codes are used wherever possible. Try and avoid overestimating the complexity of the services being delivered.

Conducting Regular Audits

Doing regular internal audits help identify billing errors, any discrepancies, or areas of improvement. Scheduling periodic reviews of your optometry billing practice in New York helps you catch mistakes early on. This makes sure everything is in alignment with New York State regulations. An audit reviews coding accuracy, documentation quality, and compliance with payer requirements

Training the Billing Staff or Partnering with a Billing Provider

If you have an in-house billing team for your optometry practice, it is very important to make sure that the team is well trained in both New York’s state regulations as well as national billing standards. This includes having knowledge of proper coding systems, knowing the importance of documentation, and how to avoid common billing mistakes.

If outsourcing is an option, you should definitely consider it as running an optometry practice in New York is hard enough. The service provider takes on all your internal tasks, including complexities of optometry billing and coding, and compliance of running a practice in the New York state. Choose a reputable billing provider, like Instapay Healthcare Services, that specializes in optometry billing in New York. Instapay Healthcare Services ensures its solutions are all in compliance with all the regulatory requirements. This reduces the risk of any potential errors, and improves the accuracy of your claims.

Hiring a Professional Optometry Coding and Billing Services Provider Based in New York

Adherence with New York’s State regulations on optometry billing is an intricate as well as time consuming process. Having an experienced optometry coding and billing provider that specializes in New York’s rules and regulations, like Instapay Healthcare Services, you streamline your optometry billing processes. With reduced risk of errors, Instapay Healthcare Services ensures full compliance with state and federal regulations.

Offering customized solutions for optometry practices based in New York, Instapay Healthcare Services’ expert team ensures claims are coded and submitted accurately, and in a timely manner. With our experience and expertise in New York State billing regulations, we help you avoid costly mistakes, to maintain a steady cash flow.

Conclusion

Optometry practices in New York must adhere to billing regulations set by the state as well as the federal laws. Financial health and reputation of your practice in New York is maintained by staying informed about the latest regulations, using the correct codes, maintaining thorough documentation, and working with professional billing services. This is how you make sure that your optometry practice remains compliant while also having maximized its revenue potential.

A reputable service provider for optometry in New York is Instapay Healthcare Services. Following all regulations, and maintaining a streamlined workflow, we take off your billing and coding burden.