Fee Schedule Review Starts With Your Top 20 Codes
A small number of codes carries most eye care revenue. For a typical ophthalmology practice, the top 20 codes by volume and dollars include exam and E/M visits, OCT, visual fields, injections and cataract surgery. We start the review there and extend it to every code with meaningful volume.
| Step | What we measure |
|---|---|
| 1. Volume | Units and allowed dollars for each code, by payer, over the last 12 months |
| 2. Medicare baseline | 2026 Medicare allowed amount for your locality |
| 3. Payer rate | Each payer's allowed amount as a percentage of Medicare |
| 4. Weighted rate | A single weighted percentage per payer based on your real mix |
| 5. Contract check | Actual payments against contracted rates to find underpayments |
The weighted rate is the number that matters. A payer that pays well on exams but poorly on injections may look fine code by code and still be your weakest contract.
What Changed in the 2026 Medicare Fee Schedule?
The 2026 Medicare Physician Fee Schedule raised the conversion factor to $33.4009 for practices outside a qualifying APM, a 3.26% increase. It also applied a 2.5% efficiency adjustment to the work RVUs of most non-time-based services. Eye exam codes were exempt. Surgical codes were not, and practice expense changes cut some surgical codes further. The 2026 Medicare rate for 66984 is $462.94, down from $521.75 in 2025.
Contracts tied to a percentage of current-year Medicare moved with those changes. Contracts tied to a fixed year's Medicare rates, or to fixed dollar amounts, did not. We check which kind each of your contracts is.
Common Eye Care Underpayments From USA Payers
Underpayments hide inside claims that look paid. These five types appear most often in eye care reviews across the USA.
- Payers still paying an older year's rates after a contract update
- Bilateral diagnostic tests paid as one eye
- Multiple procedure reductions applied to services that are exempt
- Drug lines paid below the contracted ASP-based rate
- Your own charge set below a payer's allowable, capping payment at your charge
Once found, underpayments are recovered through payer reprocessing requests or appeals, and our payment posting team adds the correct rates to posting so future short payments are flagged the day they arrive.
Fee Schedule Data for Payer Contract Talks
Payers respond to data, not requests. We prepare a short package for each contract you want to renegotiate. It includes your volume with that payer, their weighted rate against Medicare, how that compares with your other payers and the services where the gap is largest. Your practice or your contracting advisor takes it to the payer. We do not negotiate on your behalf, but we give you the numbers to do it well.
How Often Should You Review Your Fee Schedule?
Run a full review once a year, after the Medicare final rule is published and new rates take effect in January. Run a focused review for each commercial contract at least 120 days before its renewal date. A fee schedule review is part of our free ophthalmology billing audit for new clients and is available as a standalone project.