Ophthalmology billing code eligibility and reimbursement ranking system

A computer-implemented method performed by at least one processor to automatically generate a payer-specific reimbursement ranking for an encounter, the method comprising:

• obtaining ophthalmology encounter data and payer information from an electronic medical record;
• generating, based on the ophthalmology encounter data and the payer information, a patient billing profile data structure that includes a reimbursement identifier corresponding to a payer associated with the encounter;
• applying a plurality of eligibility rules to the patient billing profile and the ophthalmology encounter data to determine eligibility of encounter codes for the encounter, including determining whether the patient is new or established;
• based on the applied plurality of eligibility rules, determining a candidate set of eligible encounter codes including ophthalmology-specific codes and evaluation-and-management codes;
• obtaining, for each encounter code in the candidate set of eligible encounter codes, a payer-specific allowable reimbursement amount using the reimbursement identifier;
• and
• generating a reimbursement-based recommendation by ranking the candidate set of eligible encounter codes according to the obtained payer-specific allowable reimbursement amounts and causing presentation of at least one recommended encounter code within the electronic medical record.

A computer program product comprising a program of instructions tangibly embodied on a non-transitory computer-readable medium that, when executed by one or more processors, cause the one or more processors to perform operations to automatically generate a payer-specific reimbursement ranking for an ophthalmology encounter, the operations comprising:

• obtaining ophthalmology encounter data and payer information from an electronic medical record;
• generating, based on the ophthalmology encounter data and the payer information, a patient billing profile data structure that includes a reimbursement identifier corresponding to a payer associated with the encounter;
• applying a plurality of eligibility rules to the patient billing profile and the ophthalmology encounter data, comprising:
• determining a patient status indicating whether the patient is new or established,
• applying a first subset of eligibility rules configured to evaluate ophthalmology-specific encounter code eligibility based on documentation criteria, and
• applying a second subset of eligibility rules configured to evaluate evaluation-and-management encounter code eligibility based on medical decision-making criteria;
• based on the applied plurality of eligibility rules, determining a candidate set of eligible encounter codes including ophthalmology-specific codes and evaluation-and-management codes;
• obtaining, for each encounter code in the candidate set of eligible encounter codes, a payer-specific allowable reimbursement amount using the reimbursement identifier;
• and
• generating a reimbursement-based recommendation by ranking the candidate set of eligible encounter codes according to the obtained payer-specific allowable reimbursement amounts and causing presentation of at least one recommended encounter code within the electronic medical record.