Here are some tips, including some referring to specific item numbers, to maximise your Medicare claims. Read this blog now.
The freedom offered to optometrists to charge a private fee above Medicare bulk billing came into effect on the 1st of January 2015.1 However, the experience (and fear) of many practice owners is that this change to private billing is met with fierce resistance from patients, causing many to stay with the scheduled Medicare fees. Another challenge for optometry is the rise of online sales of glasses and contact lenses. Although there are various strategies to grow revenue in the face of these challenges, there are always ways you can ensure you’re at least getting the most out of your Medicare billing. Here are some tips, including some referring to specific item numbers, to maximise your Medicare claims.
1. Understand the Medicare item codes.
To bill Medicare effectively, naturally, you will need to have a solid understanding of how to apply each item number. Some will be more frequently used than others – for example, 10911 or 10910 compared to a 10930. However, those less often used can be a good way of maximising your billing if you can remember them. For example, a 10943 for diagnosis of a significant binocular or accommodative dysfunction in patients aged 3-14 years old can be used in conjunction with any of the item codes for an initial or subsequent consultation.2 This means you can bill (and get paid for) a 10943 in addition to a 10918, 10910, or 10912-10914.
In another example, item numbers 10921 to 10930 may not be used frequently unless your practice sees many specialty contact lens fits. However, the 10921 for myopia of -5D or higher, 10922 for manifest hyperopia of +5D or higher, and 10923 astigmatism of -3D or higher may be used more often than some optometrists realise. Remember that the eligibility criteria for these item numbers require only one eye to meet the stated spherical equivalent refractive error.
2. Make sure you’re submitting a claim for every eligible patient.
You’re never getting paid if you never submit the claim to Medicare! At regular intervals, whether at the end of every day or the week, go through your appointments to ensure that every patient consult has at least one item number attached (provided the consult is eligible for a Medicare rebate). Ensure staff members understand whose responsibility it is to submit the batch of Medicare claims periodically so no one is assuming someone else has done it.
3. Attend to claims that have been rejected.
If you accidentally billed a 10911 for a patient under 65 years old and it has been knocked back, don’t leave it sitting there. Put the names or patient numbers of rejected claims on a to-do list to ensure you don’t forget about it later.
4. Use the 10912 to your advantage.
The 10912 item number is used for patients with “a significant change in visual function requiring comprehensive re-evaluation”.1 It is a useful way of charging for a comprehensive consultation for eligible patients presenting within the 12-month limit for a comprehensive exam for patients 65 years or older and within the 3-year limit for those under 65. A “significant change” can include:2
- A deterioration of visual acuity by at least 2 lines on the VA chart, whether corrected or uncorrected
- A change to a visual field defect or finding previously undetected visual field loss
- Changes to binocular vision findings
- A deterioration to contrast sensitivity or finding previously undetected contrast sensitivity loss
Note that the 10912 item cannot be used if this is a first-time patient; he or she must have been seen at the practice before.
5. Use the 10914 to your advantage.
The use of item 10914 is applied to a “progressive disorder requiring comprehensive re-evaluation”.1 This item can be used within the 12-month/3-year age-related limits for comprehensive consultations. However, some optometrists may forget that a “progressive disorder” can cover many conditions, some of which are fairly commonly encountered in routine practice. Listed by Optometry Australia, the 10914 can include:2
- Age-related macular degeneration
- Diabetic macular oedema
- Corneal dystrophies
- Progressive myopia
Even if you end up not finding any significant progression, if you provided a comprehensive examination lasting more than 15 minutes to determine that fact, you can bill the 10914. Many optometrists may find they use the 10914 item code most frequently for cataract, given the frequency of this diagnosis. Remember, even grade 1 nuclear sclerosis can tip a patient over into 10914 eligibility. The 10914 can be used for a first-time patient presenting to the practice.
6. Organise your appointment book efficiently.
Unsurprisingly, the more patients you see in a given day, the more opportunity you will have to bill Medicare. However, Medicare does have time requirements to be able to bill specific item codes. For example, comprehensive consultations attracting a 10910, 10911, 10912, 10913, 10914, and 10915 must last for at least 15 minutes. Though there may be varying opinions on how long a standard appointment timeslot should be – some corporate practices are known to routinely book 20 minute appointments – there are ways you can organise your appointment book more efficiently to fit in more patients without compromising on your quality of care.
Consider whether upskilling your dispensing or support staff to perform pre-testing is suitable for your practice. You can train other staff members to conduct tests such as non-contact tonometry, autorefraction, or fundus photography, all of which can reduce the time the patient needs to spend with the optometrist. This may allow you to fit more appointments within the day.
Train your reception staff thoroughly to book appointments correctly and efficiently. For example, an initial presentation of a sore, red eye may be booked for the standard half-hour consultation and attract a 10913. However, review of the sore eye is likely to only be eligible for a 10918. Knowing that you will only be receiving half the fee of an initial comprehensive exam and that the review is unlikely to need 30 minutes, it would be more efficient both time-wise and billing-wise to book this review appointment for a lesser amount of time, for example, 15 minutes. Similarly, while a patient is dilating or waiting for cycloplegia to set in, another appointment could be fit into that space. Clear communication between the optometrist and the staff responsible for making the appointments can help with slotting bookings efficiently.
Modern optometry practices face significant challenges in generating enough revenue to keep the clinic running, offer their staff reasonable remuneration, and maintain a high standard-of-care for their patients. Though Medicare has a long way to go in fairly adjusting their indexation for optometry items, a switched-on practice can still undertake steps to ensure they’re maximising their Medicare billing.
- Australian Government Department of Health. Medicare Benefits Schedule Book, Optometrical Services Schedule. 2016. Available at: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/CF1350417910EAE6CA25817D0015AF5B/$File/201709-Optom.pdf. (Accessed December 2022).
- Optometry Australia. Medicare Benefits Schedule Item Use Guide. 2015. Available at: https://www.optometry.org.au/wp-content/uploads/provided/Practice_Professional-Support/Medicare_PrivateBilling_HealthFunds/Medicare-items_explanatory-notes/optometry_mbs_item_use_guide_-_october_2018.pdf. (Accessed December 2022).