Eye Care Billing and Coding Procedures in Canada

The Canadian healthcare system offers publicly funded medical services, including eye care.  However, coverage details and billing procedures vary significantly across provinces. This article provides a comprehensive guide for optometrists, ophthalmologists, and other eye care professionals to navigate the intricacies of eye care billing in Canada.

Navigating the Canadian Healthcare System for Eye Care

Canada has a publicly funded healthcare system that operates under the principles of the Canada Health Act, thus ensuring access to necessary medical services for Canadian citizens and permanent residents.

Public healthcare, often referred to as Medicare, is primarily funded through taxes and administered by provincial and territorial governments, each of which has its own healthcare plan. These plans dictate coverage details for eye care services provided by optometrists and ophthalmologists. 

Generally, Canadian citizens and permanent residents qualify for provincial healthcare coverage. Public plans typically cover medically essential eye examinations, diagnostic tests, and some treatments. Preventive care, such as routine eye exams and eyeglasses, may have limited coverage or require additional patient contributions. 

Additionally, while public healthcare covers most essential medical services, private healthcare is also available. It offers supplementary services that may not be included in provincial plans, such as certain prescription medications, elective surgeries, and vision care beyond basic eye examinations.

Commonly Used Eye Care Billing Codes

Accurate billing is essential for the financial sustainability of eye care practices. Below is a list of the most commonly used billing codes in ophthalmology and optometry in Canada. It’s important to note that, while this list represents a selection of commonly used codes, numerous other codes exist for specific procedures, materials, and follow-up care.

Optometry Billing Codes

Alberta Health Care Insurance Plan (AHCIP) optometry billing codes: 

• B650: A complete oculovisual assessment including refraction and the writing of an optical prescription for the fitting of corrective lenses
• B651: A partial vision examination (two or more single diagnostic procedures)
• B658: Visual fields testing (peripheral, central, perimacular, screening)
• B900: Consultation
• B906: Computer-assisted visual fields (CAVF) testing - technical
• B907: Computer-assisted visual fields (CAVF) testing - interpretation

Ontario Health Insurance Plan (OHIP) optometry billing codes:

• V402: A minor oculovisual assessment for patients 19 years or under and 65 years or older. It covers history taking, visual acuity tests, refraction (determining corrective lens power), and ocular health assessments.
• V404: This code represents a periodic oculovisual assessment for patients 19 years old and younger. Limit is one exam per patient every 12 consecutive months. 
• V406: This code signifies a periodic oculovisual assessment for patients aged 65 and over. Limit is one exam per patient every 12 consecutive months.
• V408: This code represents a minor oculovisual assessment for patients aged 20-64 who have a qualifying medical condition, such as diabetes or glaucoma.
• V409: This code signifies a major eye exam for patients aged 20-64 for one of the following conditions: diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus, recurrent uveitis, optic pathway disease.
• V410: This automated visual field assessment is used to map the patient’s visual fields for patients 19 years or under and 65 years or older. Insured eligibility varies. 

Ophthalmology Billing Codes 

Ontario Health Insurance Plan (OHIP) Ophthalmology Billing Codes:

• A230 (Orthoptic Assessment): This code represents an assessment of eye movement control and coordination performed by an orthoptist (a healthcare professional specializing in these areas).
• A231 (Consultation): This code signifies a comprehensive consultation with an ophthalmologist for a new eye condition or complex case.
• A233 (Specific Assessment): This code represents a focused assessment for a specific eye condition, such as a cataract evaluation.
• A236 (Repeat Consultation): This code signifies a follow-up consultation with an ophthalmologist regarding an existing condition.
• C235 (Consultation): This code represents a consultation with an ophthalmologist in a non-emergency hospital setting.

Medical Services Plan (MSP) ophthalmology billing codes: 

• 02010 (Consultation): This is the base code for a standard ophthalmology consultation for any new patients or follow up patients that haven’t been fully assessed in the last 6 months.
• 02014 (Orthoptic Evaluation): This code represents an assessment of eye movement control and coordination performed by an ophthalmologist.
• 02017 (Oculo-Motor Function Test): This code signifies a specific test for evaluating eye movement function.
• 22016 (Pachymetry): This code represents measurement of corneal thickness, often used in conjunction with other examinations.
• 02148 (Cryotherapy of Eyelids for Trichiasis or Tumour): This code signifies the freezing treatment of abnormal eyelash growth or eyelid tumors.
• 02150 (Chalazion removal): This code represents the removal of a chalazion, a type of eyelid cyst.
• 02153 & 02154 (Ectropion/Entropion): These codes represent surgeries to correct eyelid malpositions (outward or inward turning). The specific code depends on the complexity of the procedure.
• 02160-02163: These codes represent various surgical procedures to correct strabismus (misalignment of the eyes). The specific code depends on the number of muscles involved in the correction.
• 02160 (Ptosis): This is a code for ptosis repair or repair of the eyelids when they are droopy.

Medical Service Plan (MSP) Optometry Billing Codes:

‍02899 - Full Exam
02898 - Minor Exam
02891 - Extended Diagnostic Testing 
02882 - OCT scans
02881 - Fundus Photos
02893 - Visual Fields
96223 - EVF Form + Visual Field Testing

Billing tips specific to performing visual fields: 02893 can be billed together with 02899 / 02898s or standalone for a medical condition (eg. glaucoma 365.xx , retina 362.xx , or choroid 363.xx) the exact eligibility is up to the discretion of the doctor ordering the visual fields. You can also bill 02893 for V6751 if you are following side effects of a specific medication (eg. plaquenil. 

Visual Field specifically - MSP must be notified by the College that you are able to bill for visual fields so you must demonstrate proof that you have a machine capable of automated perimetry. 

To ensure accurate billing, select the most specific code that accurately reflects the service provided. Maintain detailed patient records to document the nature of the examination, tests performed, and diagnoses made. You should also continue to stay updated on provincial healthcare plan guidelines and billing code interpretations specific to your region.

Provincial Differences in Eye Care Billing 

Eye care billing procedures in Canada vary significantly across provinces, reflecting different healthcare policies and regulations. Understanding these differences is crucial for accurate billing and compliance.

Ontario

In Ontario, the Ontario Health Insurance Plan (OHIP) covers comprehensive eye exams for individuals under 20, over 65, and those with specific medical conditions such as diabetes. The refundable amounts for these services are predetermined by OHIP, and co-pays are generally not applicable for covered services. However, examinations for other demographics may require patient co-pays. Regulations specify the frequency of OHIP-covered exams and limit coverage for certain vision correction methods.

Visit the Ontario Health Insurance Plan (OHIP) website at https://www.ontario.ca/page/your-health for the latest information on eye care coverage and billing procedures in Ontario. 

Quebec

Quebec's Régie de l'assurance maladie du Québec (RAMQ) covers annual eye exams for children under 18, seniors 65 and older, and individuals with medical conditions like diabetes or glaucoma. Co-pays may apply for services not fully covered by RAMQ, and optometrists need to be familiar with the provincial fee schedule. RAMQ establishes eligibility criteria for coverage based on income and social security status.

The RAMQ website provides current details on eye care coverage in Quebec https://www.ramq.gouv.qc.ca/fr (in French).

British Columbia 

In British Columbia, the Medical Services Plan (MSP) provides coverage for annual eye exams for all ages, but some diagnostic tests or materials may carry patient co-pays. This province has regulations outlining which materials and procedures qualify for coverage under the provincial health plan.

The Ministry of Health website offers resources on the Medical Services Plan (MSP) for eye care, accessible at https://gov.bc.ca/health.

Alberta

Alberta's Health Care Insurance Plan (AHCIP) covers comprehensive eye exams for children under 19 and seniors 65 and older. It also provides coverage for individuals with medical conditions such as diabetes. The refundable amounts and co-pays are regulated by AHCIP, with specific guidelines for each service.

The Alberta Health website provides information on the AHCIP and optometry billing at https://www.alberta.ca/ahcip. 

Latest Updates and Upcoming Changes

Recent updates to Canadian billing codes reflect the evolving landscape of healthcare services, emphasizing the need for precision in diagnostic and therapeutic procedures. Notably, new codes for advanced imaging techniques and expanded telehealth services have been introduced. These changes necessitate updated documentation practices and may influence reimbursement rates. 

Practitioners should stay informed about upcoming changes in healthcare law, particularly regarding the integration of digital health services. Here are some valuable resources: 

• Canadian Medical Association (CMA)
• Ontario Ministry of Health
• Alberta Health 
• Canadian Ophthalmological Society (COS)

Billing and Coding Best Practices

Accurate and timely billing submissions are crucial for the financial stability of eye care practices. To ensure accuracy, always verify patient information and eligibility before service delivery. Use up-to-date coding references, and verify that all codes correspond precisely with services rendered. Maintain meticulous patient records that clearly document examinations, diagnoses, and treatment plans; and regularly train staff on billing procedures and common errors to minimize mistakes. 

Common billing pitfalls include inaccurate coding, incomplete documentation and late claim submissions. To manage billing disputes and audits effectively, maintain comprehensive documentation of all services rendered and communications with patients, and promptly address discrepancies and engage with payers to resolve issues. You may also consider involving your professional association or a healthcare billing consultant for complex disputes.

Technological Advancements for Streamlined Billing 

Many types of software and tools are available to assist Canadian optometrists and ophthalmologists with examinations, medical billing, and patient management. A key innovation lies in the seamless integration with Electronic Medical Records (EMR) systems. This integration ensures accurate and efficient data transfer, reduces administrative errors, and enhances patient care by providing a comprehensive view of patient history and billing information.

The integration of EMRs with billing systems offers numerous benefits, including real-time access to patient information, automated coding and billing processes, and improved compliance with regulatory requirements. These systems also facilitate better communication between healthcare providers and insurance companies, expediting the reimbursement process.

Future trends in billing technology, such as AI and machine learning, promise to further revolutionize the field. AI can automate routine tasks, identify billing errors, and optimize coding accuracy. Machine learning algorithms can predict claim denials and provide insights to enhance billing practices. These advancements have the potential to significantly improve efficiency and accuracy in medical billing, allowing eye care professionals to focus more on patient care.

Please note that billing codes and processes are subject to change. Virtual Field is not providing financial or business advice. For the most current information, consult your provincial healthcare plan guidelines or a qualified professional.