Texas optometrists are no strangers to audits. With the growing scrutiny from both public and private payers, many practices are finding themselves under the microscope. While audits can feel intimidating, understanding what triggers them—and how to proactively prevent them—can keep your practice financially secure and in compliance.

Why Are Texas Optometrists Being Audited?

Audits can be initiated by commercial insurers, Medicare, Medicaid, or third-party vision plans. In Texas, several trends have increased the likelihood of optometry audits:

1.Overuse of Comprehensive Eye Exam Codes (92014, 92004)

Carriers flag practices that bill a high volume of comprehensive eye exams, especially when documentation doesn't clearly support a full exam. If these codes are used as a default rather than based on clinical necessity, it could trigger an audit.

2. Excessive Use of Advanced Diagnostic Testing

OCTs, visual fields, fundus photography, and other tests are essential, but overutilization without clear medical justification can raise red flags. Texas payers are particularly watchful of providers who routinely bill for multiple diagnostic services in a single visit.

3. Improper Billing of Vision vs. Medical Insurance

Misclassifying a routine eye exam as a medically necessary visit—or vice versa—is a common issue. Texas optometrists sometimes struggle with patients having both medical and vision plans, leading to billing confusion that may appear fraudulent to payers.

4. High Volume of Certain Procedures or Devices

Frequent billing of contact lens fittings, punctal plugs, or scleral lenses without robust documentation can also prompt a review, especially if these services are billed more often than the average for Texas providers.

5. Medicaid Managed Care Scrutiny

With Texas Medicaid transitioning to managed care models, optometry claims are under tighter review. Discrepancies in billing patterns, missing modifiers, or inaccurate patient eligibility checks can result in retroactive denials and audits

How to Stay Off the Radar

While no optometry practice is immune to audits, there are proactive steps Texas providers can take to reduce their risk:

Ensure Accurate and Detailed Documentation

Every CPT or HCPCS code you bill should be backed by detailed clinical notes. Don’t rely on templated EHR entries; customize your documentation to reflect the patient’s actual condition and services rendered.

Train Your Billing Staff Thoroughly

Many audit triggers are tied to human error. Make sure your billing team understands the nuances of optometry coding, particularly in differentiating medical from routine visits and applying modifiers correctly.

Perform Internal Chart Audits Regularly

Set aside time quarterly to self-audit a sample of charts. This helps identify inconsistencies or overuse patterns before an external auditor does.

Avoid Copy-Paste Pitfalls in EHR Systems

Payers can detect repetitive notes across multiple visits or patients, which may suggest upcoding or falsified records. Be specific and update your EHR notes for each patient encounter.

Use Expert Billing Partners

Partnering with a billing service that understands Texas-specific payer requirements—like Instapay Healthcare Services—can help your practice avoid costly mistakes and stay audit-ready year-round.

Final Thoughts

Audits aren’t just about fraud—they’re often about patterns that suggest billing carelessness. Texas optometrists who stay vigilant about their coding practices, documentation habits, and payer rules will not only reduce their audit risk but also improve reimbursement accuracy and patient care.

Need help navigating billing complexities in Texas? Contact Instapay Healthcare Services—your partner in optometry billing compliance and revenue optimization.