Medical or routine, right eye or left, insurance or patient: every eye claim starts with getting those right. California Billing Services provides ophthalmology medical billing services for eye practices across California. Our coders bill eye exams, diagnostic testing, cataract surgery, premium lenses, retina injections, glaucoma and oculoplastic procedures, and they separate what insurance pays from what the patient or vision plan pays before each claim goes out.
97%
Clean claim rate
32
Days in AR
97%
Net collection rate
<5%
Denial rate
Eye care billing has more decision points per visit than almost any specialty. A small miss repeats across every clinic day. These are the five we close first.
A visit for new glasses belongs to the vision plan; a visit for flashes and floaters belongs to medical insurance. Bill the wrong one and the claim denies or the practice gets paid the lower rate. We set the payer from the chief complaint and diagnosis before the claim is built.
Medicare excludes refraction by law, and premium IOL upgrades are the patient's cost. If the front desk doesn't collect them, they're usually written off. We set up patient-paid charges and disclosures so they're collected.
Some tests are paid per eye and some per patient, and payers limit how often they cover OCT and visual fields. We apply laterality and frequency rules to every test.
Anti-VEGF drugs are among the highest-dollar claims in medicine. A wrong unit count, missing NDC or missing JZ or JW modifier can deny the whole claim. We match drug, dose and units to the injection record.
Cataract surgery carries a 90-day global period, and the second eye often falls inside the first. We track every global window and apply 24, 79 and the right side modifiers only when they're supported.
Find your biggest leak with a free 90-day audit.
Built around your care
Medical, vision plan and patient-paid charges each follow their own rules. We set the payer from the chief complaint and diagnosis before the claim is built, so your team can focus on the exam.
As a full-service medical billing company, California Billing Services gives eye practices one accountable team for the whole revenue cycle.
Medical and vision benefits checked, with the right payer set for each visit before the patient is seen.
Explore serviceAnti-VEGF drugs, surgery and oculoplastic procedures approved, with renewal dates tracked.
Explore serviceEye visit codes, E/M, testing, surgery, drugs and modifiers coded from the exam and operative notes.
Explore serviceLaterality, frequency limits, global periods and NCCI edits checked before submission.
Every payment compared with your contracted rates, including drug reimbursement.
Medical necessity, frequency, drug and global period denials worked the day they arrive.
Explore serviceHigh-dollar drug and surgery claims worked first; old AR recovered on contingency.
Explore serviceOphthalmologists, optometrists and ASCs enrolled with Medicare, Medi-Cal, commercial and vision plans.
Explore serviceRefraction, premium lens and deductible balances collected with clear estimates and statements.
When a patient has both a vision plan and medical insurance, we check both at check-in and tell your front desk which one to bill, so the patient isn't surprised and the practice isn't paid the lower rate.
| Visit reason | Who usually pays | How it's billed |
|---|---|---|
| Routine exam for glasses or contacts, no medical complaint | Vision plan (such as VSP, EyeMed, Davis Vision or Spectera) or the patient | Vision plan codes or eye visit codes with a refractive diagnosis, plus refraction |
| Symptoms, injury or eye disease (red eye, flashes, blurred vision from cataract) | Medical insurance | Eye visit code or E/M with the medical diagnosis |
| Ongoing care for glaucoma, diabetic eye disease or macular degeneration | Medical insurance | Eye visit code or E/M, plus covered testing |
| Refraction during a medical visit | Patient or vision plan (excluded from Medicare by law) | 92015 billed to the patient or vision plan |
| Routine exam that finds a medical problem | Depends on the plan and the documented reason for the visit | Coded to what the doctor documents; patient told before billing |
Ophthalmologists can bill either eye visit codes (92002 and 92004 for new patients, 92012 and 92014 for established) or E/M codes (99202 to 99215), but not both for the same visit. Eye codes depend on the exam elements performed; E/M codes depend on medical decision making or time. We pick the code set that the documentation supports and the payer accepts, visit by visit.
Some tests are paid per eye and others once for both eyes, so we apply RT, LT or 50 only as each payer requires. Diagnoses are coded to full specificity, including the eye and the disease stage, such as H40.1132 for moderate primary open-angle glaucoma in both eyes.
| Test | Codes | What we check |
|---|---|---|
| OCT | 92133 (optic nerve), 92134 (retina) | Only one billed per day; diagnosis matches the structure scanned |
| Visual fields | 92081 to 92083 | Diagnosis and frequency limits |
| Fundus photography and extended ophthalmoscopy | 92250, 92201, 92202 | NCCI edits with other imaging on the same day |
| Angiography | 92235, 92240, 92242 | Separate or combined study as performed |
| Biometry for cataract planning | 76519, 92136 | Billed per eye, linked to the surgery plan |
| Pachymetry, gonioscopy, topography, specular microscopy | 76514, 92020, 92025, 92286 | Medical necessity and payer coverage |
| B-scan and ERG | 76512, 92273, 92274 | Indication documented |
Cataract surgery is the highest-volume procedure in most eye practices, and every case has several billing decisions.
Standard cataract surgery (66984) and complex cataract surgery (66982) are separated by what the operative note documents, such as iris expansion devices or capsular support. Combined procedures are billed with their own codes, including endocyclophotocoagulation (66987, 66988) and drainage device insertion for glaucoma (66989, 66991). Each case carries a 90-day global period, and second-eye surgery inside the first eye's global uses modifier 79 with RT or LT. YAG capsulotomy (66821) is billed separately when it's medically necessary.
When a patient chooses an astigmatism-correcting or presbyopia-correcting lens, Medicare pays for the standard cataract surgery and lens, and the patient pays the extra cost of the premium lens and related services. We help your team give patients a written estimate before surgery, bill the covered portion to insurance and collect the patient's portion separately, so neither side is billed for the other's share.
For surgeries in an ambulatory surgery center, the ASC bills a facility claim that includes the standard lens, while the surgeon bills the professional fee. We bill and reconcile both for practices that own or partner with an ASC.
When an optometrist provides post-operative care, the surgeon bills with modifier 54 and the optometrist with modifier 55, each for their share of the global fee, with a documented transfer-of-care date and patient consent. We set up co-management billing on both sides and keep the arrangement within federal anti-kickback rules.
Leaving premium lens revenue uncollected?
A single anti-VEGF injection can be worth more than a full day of clinic visits. We bill retina care so the drug, the injection and the authorization all match.
Laser trabeculoplasty (65855), trabeculectomy (66170, 66172) and tube shunt surgery (66179, 66180), plus the visual fields and OCT that track the disease. Glaucoma diagnoses are coded with the eye and the stage, because payers use the stage to decide how often testing is covered.
Corneal transplants including DMEK (65756) and other keratoplasty codes, corneal crosslinking for keratoconus (0402T), pterygium excision (65426) and punctal plugs (68761), with global periods tracked for each surgery.
Blepharoplasty (15822, 15823) and ptosis repair (67901 to 67908) are covered only when they're functional, not cosmetic. Medicare and most plans expect visual field testing with and without the eyelid taped and photographs showing the eyelid blocking vision. We confirm that documentation before surgery, use eyelid modifiers (E1 to E4) where needed and bill cosmetic procedures to the patient.
Strabismus surgery (67311 to 67318) and pediatric eye exams billed to Medi-Cal and commercial plans with the right authorization.
Eye practices collect more from patients than most specialties. These charges are easy to lose if they aren't set up before the visit.
Noridian JE coverage rules for cataract surgery, blepharoplasty, testing frequency and anti-VEGF drugs, plus Medicare Advantage authorization and step therapy requirements. Medicare also covers one pair of glasses or contacts after each cataract surgery with a lens implant, billed by the supplier.
Medi-Cal covers medical eye care plus a routine eye exam and eyeglasses once every 24 months for children and adults, with more frequent exams when medically necessary, such as for diabetes. Lenses are made by the California Prison Industry Authority (CALPIA) optical labs, and patients who choose upgrades the lab can't provide sign for the extra cost. Many Medi-Cal managed care plans hand vision benefits to a vendor such as VSP or March Vision Care, so we confirm the right payer before the visit.
California HMO members are often assigned to an IPA or medical group that approves and pays for eye care. We check the assignment and the DOFR, and bill Anthem Blue Cross, Blue Shield of California, Health Net, Aetna, UnitedHealthcare and Covered California plans to their own rules.
VSP, EyeMed, Davis Vision and Spectera claims are billed through each plan's portal, with routine exams and materials kept separate from medical claims.
| Metric | Our result | Benchmark |
|---|---|---|
| Clean claim rate | 97% | 95%+ (HFMA) |
| Denial rate | Under 5% | 5–10% average |
| Days in AR | 32 | 30–40 (HFMA) |
| AR over 90 days | Under 10% | Under 10% (HFMA) |
| Net collection rate | 97% | 95% minimum (MGMA) |
We moved payer selection for routine vs medical visits to check-in, matched retina drug units and wastage modifiers to injection records, tracked step therapy renewals and started collecting refraction and premium lens balances that had been written off.
| Before | After 90 days | |
|---|---|---|
| Denial rate | 12% | 4.4% |
| Days in AR | 50 | 31 |
| Monthly collections | $920,000 | $1,034,000 (+12.4%) |
| Modifier | Use in ophthalmology |
|---|---|
| RT / LT / 50 | Right eye, left eye or both, per payer rules |
| E1-E4 | Upper and lower eyelids, left and right |
| 24 / 25 / 57 | Visits during a global period, on a procedure day or deciding on surgery |
| 79 | Unrelated procedure in a global period, such as second-eye cataract surgery |
| 54 / 55 | Surgical care only / post-operative care only (co-management) |
| JW / JZ | Drug discarded / no drug discarded from a single-dose vial |
| GA / GY / GZ | ABN on file / service excluded by statute / ABN not on file |
Modifier selection follows the procedure documentation, current code set and payer edits. Code examples are not a substitute for case-specific coding review.
Medical and routine visits, testing and refraction billed to the right payer.
Standard, complex and premium lens cases, with patient-paid portions collected.
Anti-VEGF drug billing, step therapy and authorization renewals.
Procedure coding and testing frequency tracked by stage.
Functional vs cosmetic documentation checked before surgery.
Professional, facility and co-management billing coordinated across providers.
A team that knows your specialty
Coders and billers familiar with eye care workflows review every claim before it goes out and keep you updated with clear monthly reporting.
Live in 2–3 weeks, with old AR worked in parallel.
Of 90 days of clinic, testing, surgery and injection claims.
BAA, EHR, ASC and payer and vision plan portal access.
Medical vs routine payer rules, patient-paid fee schedules and drug fee schedules.
New claims start with us while prior AR is worked down.
With daily charge entry and drug reconciliation.
By provider, service line and payer.
A simple percentage of net collections, with medical, vision plan and patient billing included. No setup fees.
Clearinghouse fees, eligibility checks, coding, claim submission, payment posting, denial and appeal work, patient statements and monthly reporting are included. No setup fees, no per-statement charges and a 30-day out clause after the first 90 days. Retina practices with high drug volume can request a custom quote or a free billing audit to price drug reimbursement separately. Old AR recovery available on contingency.
Example: a practice collecting $800,000 a month pays $31,200 at 3.9%. Recovering 4% more through correct payer selection, drug unit accuracy and collected patient balances adds $32,000 a month and covers the fee. Your free audit shows your own numbers first.
The California Billing Services team answers all seven in writing before you sign.
| In-house billing team | California Billing Services | |
|---|---|---|
| Cost | Coders, billers, software, clearinghouse | 3.9–4.9% of net collections |
| Medical vs routine payer decisions | Left to the front desk | Set at check-in by rules |
| Retina drug billing | Manual unit checks | Units, NDC and wastage matched every time |
| Patient-paid charges | Often written off | Estimated and collected |
| Coverage during PTO and turnover | Backlogs | Backup coverage built in |
We bill inside the ophthalmology EHR and practice management systems your team already uses. Exam findings, test results, operative notes and injection logs flow into coding with no data re-entry.
Plus Orange County, the Inland Empire and the Central Valley.
Pre-bill checks against NCCI edits, MUEs and testing frequency rules; monthly coding reviews by provider; co-management arrangements reviewed for anti-kickback risk; and support for MIPS reporting through the AAO IRIS Registry. HIPAA-compliant workflows, a signed BAA, CMIA-aligned data handling, role-based access, encryption in transit and at rest, and audit trails on every record.
Either can be correct, but not both for the same visit. Eye visit codes follow the exam elements performed; E/M codes follow medical decision making or time. We choose the set the documentation supports and the payer accepts.
Can't find what you're looking for? Contact our billing specialists
A California Billing Services specialist reviews 90 days of claims and shows you payer selection errors, retina drug denials, uncollected refraction and premium lens balances, global period issues and AR over 90 days. You keep the findings either way.
