# Routine vs Diabetic Eye Exam



## nwinn (Nov 12, 2015)

Hello - My family member has Type 2 Diabetes which he has impressively managed through meds and diet.  When he goes for his annual eye exam, they code Diabetes in addition to the exam, causing it not to be covered as a routine exam.  There are no problems with his eyes.  Is the Diabetes code required if the exam is unrelated to it?  Thank you


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## briansmith99 (Nov 12, 2015)

nwinn said:


> Hello - My family member has Type 2 Diabetes which he has impressively managed through meds and diet.  When he goes for his annual eye exam, they code Diabetes in addition to the exam, causing it not to be covered as a routine exam.  There are no problems with his eyes.  Is the Diabetes code required if the exam is unrelated to it?  Thank you



So far as we can tell the payors don't actually offer a Diabetic Eye Exam benefit.  Its a good idea and certainly what PCPs will recommend that DM patients should get an eye exam on an annual basis but there isn't a code for Diabetic Eye Exam.  

Most payors will continue to use a vision benefit if the DM diagnosis is included but not primary but some will spot the E11.9 (for instance) and route the claim to medical benefit and hit patients with a deductible or specialist co-pay etc.

When billing routine vision (refractive adjustments etc) we do not include the DM diagnosis for those specialty vision payors and will only include it for those payors we know won't penalize the patients for including their chronic medical condition.

Hope that helps!


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## adpaugel (Nov 12, 2015)

*Depends*

In my experience, if you put the diabetic codes as the primary diagnosis, it will be processed as a medical exam, not routine.


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## Cheezum51 (Nov 13, 2015)

Actually Medicare and other major insurers will pay for an annual eye health exam for those patients who have diabetes, whether they have any ocular complications from the diabetes or not. In many cases, the patients don't have to pay a deductible or copay for these exams because the insurers realize how important these annual exams are to catch problems early. These exams are also important to the patients' PCPs because assuring that their diabetic patients have annual dilated eye exams increases their HEDIS scores which are becoming more important as Medicare and other carriers move towards Pay for Performance fee schedules.

The insurers also realize that ocular diabetic problems are indicators of other possible systemic problems, even for those patients who are well controlled.

Since diabetic patients potentially pose a higher liability risk to the providers who are evaluating them for ocular complications and the decision making and patient management for those who do have complications can sometimes take a good bit of time, most providers are going to bill the exams as medical in nature versus billing them to the vision care plans (VCPs) which are not really insurance plans per se, and typically pay significantly lower fees, sometimes much more than 50% less, than a medical plan will pay for the exam.

Tom Cheezum, O.D., CPC


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## Cheezum51 (Nov 13, 2015)

*Another point*

Briansmith99, you made the following comment "When billing routine vision (refractive adjustments etc) we do not include the DM diagnosis for those specialty vision payors and will only include it for those payors we know won't penalize the patients for including their chronic medical condition."

In reality, you aren't doing the patient any favors because if their PCP is already treating their diabetes, the payors already know the patient has the chronic medical condition.

By not billing for the medical eye exam for these patients, especially if you are billing them only to the "specialty vision payers" i.e. the low fee vision care plans, you are potentially taking significant income away from the providers you bill for and they thus aren't getting paid for their skill and knowledge needed to take care of these serious chronic conditions.

If the providers you bill for have accepted this type of billing as SOP, then they really should speak with a practice management and billing consultant who would quickly tell them to bill those exams to major medical plans.

Just my opinion as an eye doctor. Disclosure: I also do billing and coding consulting work for eye care providers.

Tom Cheezum, O.D., CPC


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## briansmith99 (Nov 16, 2015)

Hello Dr Cheezum!

Great points.  However, when we are seeing diabetic patients we consistently see at the very least the refractions are falling to patient responsibility when we bill out to Medicare and the other larger insurance companies in our region.  We'd love to be able to bill medical since we are providing significantly more than the VCPs will reimburse but we are trying to avoid hitting our patients with that refraction fee or having their whole service go to deductibles.

Have you been able to bill out annual exams for DM patients including refractions to Medicare and have those processed under medical with no patient out of pocket?  Are you including DM as the primary dx?

Our experience has been that inclusion of the E11.xx or E10.xx diagnosis code even if its not the primary diagnosis (and it most frequently should be) leads to a quick decision for many payors including Medicare.  That decision is to dump the entire visit into deductibles or at the best pay for the visit and return responsibility for the refraction to the patient.

Certainly not ideal but that's what we are seeing.

Thoughts?


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## Cheezum51 (Nov 17, 2015)

Briansmith99,

When a Medicare pt was examined, we had the patient pay our refraction fee at the time of exam but we filed the 92015 with the claim sent to Medicare. We had a couple of Medigap plans in our area that would pay the refraction since that's something Medicare never paid. If they paid, we sent the pt a refund check for the refraction fee.

Another thing we did was for patients who had Medicare as well as vision care plan policies. We'd bill the Medicare first and when they denied the refraction, we'd send the denial to the vision care plan and they would often pay a refraction fee. VSP would allow this coordination of benefits. Other vision plans don't.

The bottom line is that Medicare has never paid for refractions and our patients were educated to understand that they would have to most likely pay that fee out of pocket.

We used to do everything we could so the patients wouldn't have to pay our full fees if they hadn't met their deductibles but we soon found that we were losing significant income by doing things that way.

It sounds harsh, but you have to realize that if the patient doesn't have to pay you out of pocket because they haven't met their deductible, the practice down the street that sees them for other medical care will. So, they have to pay someone at some time. It may as well be you so you get the maximum fee possible.

You also have to understand that patients now have high deductible insurance plans which they chose in order to have lower premiums. They know up front that they will have to meet those high deductibles before their insurance starts paying anything.

The bottom line is that we are running a business which has high overhead between staff, rent, insurance and all the mandated EMRs etc. If we don't maximize our income per patient, we won't be in business very long especially with reimbursements from insurers being stagnant for years.

Tom Cheezum, O.D., CPC


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## adpaugel (Nov 18, 2015)

I wish I could "like" a post on here.


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## mzkandyd (Nov 18, 2015)

If this is a routine exam and the patient "happens to have DM" then your primary diagnosis code should be "routine vision exam" and then DM should be the secondary dx code.


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## Cheezum51 (Jan 4, 2016)

I just saw this last reply. If a patient has diabetes, then any eye exam for them should be billed as a medical eye exam and not as a "routine exam" whether they have any diabetic eye complications or not.

That being said, if the pretesting person writes "routine exam" as the chief complaint, which they should NEVER do, then you would have to bill the exam as non medical and either the patient pays out of pocket or you would bill a vision care plan.

I can tell you that if your office sees many patients who "just happen to have diabetes" and you are billing them as routine non medical exams, your doctor is potentially losing tens of thousands of dollars in income every year due to the incorrect billing for their exams.

In these days of stagnant and reduced exam fees, that is not a very smart way to run an office in my opinion after having run a private practice for 37 years.

Tom Cheezum, O.D., CPC


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