The frequency of audits targeting ophthalmology practices in Pennsylvania has risen sharply over the past few years. This trend doesn’t seem to slow down anytime soon. From Medicaid investigations to RAC (Recovery Audit Contractor) audits and private payer scrutiny, ophthalmologists in Pennsylvania are under the microscope for how they bill, code, and document the services rendered.

The good news? Many of these audits can be avoided with the right billing protocols, compliance education, and coding precision.

The Pennsylvania Audit Landscape: What’s Happening?

Ophthalmology is a high-risk specialty for audits, primarily because of the frequency of diagnostic testing and procedures like intravitreal injections, cataract surgeries, and visual field tests involved. In Pennsylvania, some common audit triggers for ophthalmology include:

Eyewear and Materials: Billing Nuances

Eyewear billing under TMHP is another area that often causes confusion. TMHP has a fixed list of covered frame styles, lens materials, and enhancements. Optometrists must use specific Texas Medicaid Vision Procedure Codes when billing for these items. Attempting to bill for non-covered enhancements—such as anti-reflective coatings or designer frames—without prior authorization will lead to denials.

Furthermore, TMHP requires providers to dispense eyewear within a specified time frame and document patient receipt. Failure to do so can result in recoupment during audits. This level of detail is one of the unique challenges of optometry billing in Texas through TMHP.

• Overuse of Modifier 25 : This modifier is often applied to allow billing for an E/M service and a procedure on the same day. But when documentation doesn’t justify separate services, payers see it as a red flag.
• Improper use of Extended Ophthalmic Visits (92014) : Many practices default to comprehensive codes when intermediate codes (92012) would have been more appropriate.
• High frequency of injections (e.g., Avastin, Lucentis) without strong justification or proper documentation.
• Inconsistencies with global surgical periods, particularly in post-cataract care or YAG laser billing

How Proper Billing Can Prevent These Audits

While audits may be triggered by payer algorithms, they’re often exacerbated by avoidable errors. Instapay Healthcare Services’ strategic approach towards ophthalmology practices in Pennsylvania includes this:

1. Compliant Modifier Usage

Our team uses audit modifier usage monthly, particularly 25, 59, and 24. We ensure supporting documentation is in place and doesn’t rely on templated language that can be flagged during an audit.

3. Thorough Documentation Reviews

Our chart reviews don’t just check for complete notes—they analyze whether documentation clearly supports the complexity level and the medical necessity of procedures and testing.

A Proactive Partner in Audit Prevention

The cost of an audit goes beyond dollars—it disrupts practice operations, strains provider morale, and risks reputational damage. At Instapay Healthcare Services, we take a preventative approach by aligning your billing processes with all the compliance standards and payer expectations.

If your ophthalmology practice has experienced unusual denials, pre-payment reviews, or payer warnings, it may be time for a billing strategy overhaul. Let’s fix it before it becomes a bigger problem.

Contact us today for a no-obligation audit readiness check.