Ophthalmology Billing Services: The Billing Mistakes Costing Your Eye Care Practice $75,000+ Per Year (and How to Fix Them)

By Medtransic | February 16, 2026 | 15 min read

Quick Summary: The average ophthalmology practice loses 10 to 30 percent of annual revenue to coding errors, missed charges, and outdated fee schedules. Most of these losses are invisible — they do not show up as denied claims. They show up as smaller payments on claims that went through without issue. Here is where your practice is bleeding revenue and what Medtransic does to stop it.

If you run an ophthalmology practice, here is a number that should concern you: industry data shows that the average eye care practice loses between 10 and 30 percent of annual revenue to billing errors. Not fraud. Not denied claims that someone forgot to appeal. Quiet, invisible losses — wrong code selections that pay $20 less per visit, diagnostic tests billed on the wrong day that get bundled into the exam for free, cataract surgeries coded without the right modifier so the claim pays but pays less than it should.

For a practice collecting $1.5 million per year, that is $150,000 to $450,000 walking out the door. And the worst part? Your current billing team probably does not know it is happening because the claims are not being denied — they are just being underpaid.

At Medtransic, we specialize in ophthalmology billing services because eye care is one of the most technically complex specialties to bill correctly. This is not a pitch about how great our team is. This is a walk-through of the specific places your practice is likely losing money — and exactly how we find it and fix it.

Our team also integrates seamlessly with leading platforms, providing expert AthenaHealth EHR billing support to ensure your technology works as hard as your providers do. For new clinics, our practice launch services ensure you start with a high-performance revenue cycle from day one.

The Revenue You Are Losing Without Knowing It

Ophthalmology billing has a problem that most other specialties do not: most of the revenue loss is invisible. A denied claim is visible — someone on your staff sees it, works it, maybe appeals it. But the bigger losses come from claims that go through and get paid. They just get paid less than they should.

Here is how it happens in a typical ophthalmology practice:

None of these show up on a standard billing report as a problem. Your clean claim rate might look fine. Your denial rate might be acceptable. But you are collecting less than you earned. Medtransic's ophthalmology billing team audits for these specific revenue leaks because we know where to look.

Eye Codes vs. E/M Codes: The $20-Per-Visit Decision Your Biller May Be Getting Wrong

This is the single most impactful billing decision in ophthalmology — and most practices have no strategy for it. Every office visit, your biller chooses between two code families: the eye visit codes (92002–92014) or the standard E/M codes (99202–99215). Both describe the same visit. Both are legitimate. But they pay different amounts depending on the payer and the situation.

Here is what the reimbursement difference actually looks like:

The math is straightforward. If your practice sees 20 new patients per week and your biller defaults to 92004 instead of selecting 99204 or 99205 when the documentation supports it, that is $19 to $89 per visit lost — roughly $20,000 to $90,000 per year. For a single provider.

According to the American Academy of Ophthalmology, practices that shift from defaulting to eye codes (historically used 57% of the time for new patients) to strategically selecting E/M codes when appropriate can see a 6% increase in annual exam revenue. For a practice with $800,000 in exam revenue, that is an additional $48,000 per year from the exact same visits with the exact same documentation.

Cataract Surgery Billing: Protecting Your Largest Revenue Stream

For most ophthalmology practices, cataract surgery represents 40 to 60 percent of surgical revenue. A single cataract surgery (CPT 66984) reimburses approximately $1,800 to $2,200 depending on the payer. That means a single coding error on a cataract claim — one wrong modifier, one missing laterality indicator — costs your practice more than errors on dozens of routine office visits combined.

Here are the cataract billing mistakes Medtransic catches that most billing companies miss:

Routine vs. Complex Cataract: The $500-$800 You Are Leaving Behind

CPT 66984 is routine cataract removal. CPT 66982 is complex cataract removal — and it reimburses $500 to $800 more. The complex code applies when the surgeon documents conditions like small pupils requiring mechanical dilation, dense brunescent cataracts requiring phaco chop technique, pseudoexfoliation with zonular weakness, prior vitrectomy or corneal transplant, or pediatric cataracts. Many surgeons do document this complexity in their operative notes but their biller still defaults to 66984 because they do not know to look for it. Medtransic's coding specialists review every cataract operative report for complexity indicators and bill 66982 when the documentation supports it.

The 90-Day Global Period Trap

Every cataract surgery carries a 90-day global period. Your biller knows that post-op visits during those 90 days are included. But here is what most billers get wrong: services that are unrelated to the cataract surgery ARE separately billable during the global period. A glaucoma pressure check, a retina concern, a dry eye flare-up — if it is not related to the cataract recovery, it should be billed with modifier -24 (unrelated E/M) and paid in full. Most billing companies skip these because they see the patient is in a global period and assume nothing is billable. Medtransic tracks every patient's active global periods and flags every encounter that qualifies for separate billing.

Second Eye Surgery: Modifier -58 Revenue

When you perform cataract surgery on the second eye during the first eye's global period, the second surgery is fully billable with modifier -58 (staged procedure). It also starts its own 90-day global period. If your biller does not know this, the second eye surgery either gets denied (because it looks like a duplicate) or never gets billed at all. Either way, you just lost $1,800 to $2,200.

Retina Injections: The Drug Billing Errors That Cost Practices Thousands Per Month

If your practice performs intravitreal injections for macular degeneration, diabetic retinopathy, or retinal vein occlusion, drug billing may represent 35 to 50 percent of your operating costs. Anti-VEGF medications like Eylea, Lucentis, and Avastin are expensive, and the billing rules are unforgiving.

Here is where practices lose money on retina injection billing:

For a retina practice performing 30 to 50 injections per week, getting drug billing right is not a billing detail — it is a practice survival issue. The margin on anti-VEGF drugs is already thin. Billing errors on the drug side can turn a profitable injection service into a money-losing one. Medtransic's ophthalmology billing team includes specialists who understand drug reimbursement mechanics specific to retina practices.

Diagnostic Testing Revenue: Stop Giving Away OCTs and Visual Fields

Ophthalmology practices perform diagnostic testing on 70 to 85 percent of patient encounters. OCT scans, visual field tests, fundus photography, corneal topography, optic nerve imaging — each of these has its own CPT code and its own reimbursement. But the revenue only comes in if the test is billed correctly, scheduled on the right day, and documented with medical necessity.

The three most common ways practices give away diagnostic testing revenue:

1. Scheduling Tests on the Same Day as Surgery

When you perform an OCT (92134) or visual field (92081-92083) on the same day as a surgical procedure, NCCI bundling edits often bundle the diagnostic test into the surgery — meaning the test pays zero. The solution is simple: perform necessary pre-operative diagnostics on a separate visit date before the surgery. But this requires your billing team to coordinate with your surgical scheduler, which most general billing companies do not do. Medtransic flags scheduling conflicts before they happen.

2. Missing Modifier -25 on Same-Day E/M + Test

When a patient receives both an office visit and a diagnostic test on the same day, the E/M code needs modifier -25 to indicate it was a separate, significant service. Without -25, many payers bundle the E/M into the test — and you lose the office visit reimbursement entirely. That is $80 to $180 per visit, gone.

3. No Medical Necessity Documentation for Repeat Testing

Payers have frequency limits on diagnostic tests. Medicare, for example, limits how often you can bill OCT for glaucoma monitoring. If your documentation does not establish medical necessity for each test — why this patient needed this test at this interval — the claim either denies or gets flagged for audit. Medtransic's claim submission process verifies medical necessity documentation against payer-specific frequency limits before every diagnostic claim goes out.

The Post-Op Visits You Should Be Billing But Are Not

This is one of the biggest hidden revenue opportunities in ophthalmology. Every major surgery — cataract extraction, glaucoma surgery, retinal detachment repair — carries a 90-day global period. During those 90 days, routine follow-up care is included in the surgical fee. But not everything is routine, and not everything is related to the surgery.

Medtransic recovers revenue from global periods in three ways that most billing companies miss:

Industry data indicates that global period billing errors account for approximately 12 percent of surgical claim denials in ophthalmology. But the bigger issue is the claims that never get submitted at all — the unrelated visits that your biller never bills because they see the patient is post-op and assume it is all bundled. Medtransic's global period tracking catches both problems.

5 Ophthalmology Billing Mistakes and What They Actually Cost You

Based on our experience managing ophthalmology revenue cycle management at Medtransic, these are the five most expensive patterns we see when we take over billing from another company or from an in-house team.

1. Defaulting to Eye Codes Without Payer Analysis

Annual cost: $15,000 – $90,000 per provider. Most ophthalmology billers default to 92014 for every established patient visit and 92004 for every new patient visit. They have been doing it this way for years. But with the 2021 E/M documentation changes, the E/M codes now have simpler documentation requirements and often higher reimbursement. A practice that never evaluates whether E/M codes pay more for specific payers and visit types is systematically underbilling. Medtransic runs payer-specific reimbursement comparisons and selects the higher-paying code for every visit.

2. Not Billing Complex Cataract (66982) When Documented

Annual cost: $5,000 – $40,000 depending on surgical volume. The difference between routine (66984) and complex (66982) cataract reimbursement is $500 to $800 per case. If even 10% of your cataract volume qualifies as complex — and many do — that is significant revenue. But the biller has to read the operative report and recognize the complexity indicators. Most do not.

3. Outdated Fee Schedules

Annual cost: $20,000 – $50,000 or more. If your practice has not reviewed and renegotiated its payer fee schedules in the last two to three years, you are billing at rates that do not reflect current reimbursement levels. Payer rates change. New codes get added with new rates. Your contract may allow for annual adjustments that nobody on your team requested. Medtransic's payer contract negotiation service reviews your fee schedules against current market rates and identifies renegotiation opportunities.

4. Missing the JW Modifier on Drug Waste

Annual cost: $2,000 – $8,000. Every time your practice draws from a single-use vial and discards unused medication, that discarded drug is reimbursable with the JW modifier. This applies to anti-VEGF injections, steroid injections, and other injectable medications. Many billing teams do not know the JW modifier exists or do not have a process to capture waste documentation. Medtransic appends JW on every qualifying injection claim.

5. Prior Authorization Failures on Surgery and Imaging

Annual cost: $10,000 – $50,000 in denied surgical claims. Cataract surgery, glaucoma procedures, advanced imaging (OCT angiography, visual fields beyond frequency limits), and specialty drugs almost always require prior authorization. Without it, the entire claim is denied — and by the time you realize it, the timely filing window may have passed. Medtransic initiates prior authorization the moment surgery is scheduled and confirms approval before the procedure date.

Why General Billing Companies Fail Ophthalmology Practices

Ophthalmology is not like billing for a primary care office or even most other specialties. Here is what makes it different — and why a general billing company will consistently leave money on the table:

The common thread is that ophthalmology billing requires domain expertise your general billing company does not have. They might be great at billing primary care E/M visits. But ophthalmology has its own code families, its own payer rules, its own surgical complexity, and its own drug billing requirements. This is why Medtransic assigns dedicated ophthalmology billing specialists — not general billers who happen to have your account.

How Medtransic Handles Ophthalmology Billing Differently

At Medtransic, we do not just process claims. We manage a high-performance revenue cycle designed specifically for ophthalmology practices. Our team of ophthalmology billing experts, certified coders, and RCM analysts work as an extension of your practice to maximize every dollar of earned revenue.

When you partner with Medtransic, your practice gains:

• Dedicated Ophthalmology Billing Team: Specialists who speak your language and understand ophthalmic terminology, anatomy, and surgical procedures.
• Expert Coding Reviews: Every surgical claim and complex encounter is reviewed by an AAO-certified coder to ensure accuracy and maximum reimbursement.
• Proactive Denial Management: We do not just resubmit denials; we analyze root causes and implement workflow changes to prevent them from happening again.
• Payer Contract Optimization: Regular reviews of your payer contracts and fee schedules to ensure you are being paid market-leading rates.
• Transparent Reporting: Real-time access to your practice's financial performance through our RCM dashboard, with detailed insights into collections, adjustments, and AR aging.

Is It Time to Switch Your Billing Company?

If your current billing company cannot answer technical questions about JW modifiers, staged procedure modifiers, or E/M vs. eye code reimbursement rates, they are likely costing you money every day. Your ophthalmology practice deserves a billing partner that understands the complexity of eye care.

Stop leaving revenue on the table. Contact Medtransic today for a free, no-obligation audit of your ophthalmology billing and see exactly where your practice is leaking revenue.