Ophthalmology and Optometry Coding Alert

There are times when you should report S0620/S0621 -- we'll tell you when

A patient presents for what your ophthalmologist expects will be a routine vision exam, but then the physician finds cataracts. Should you still report the service to the patient's vision plan or to his medical plan because the ophthalmologist found a medical problem? Or both?

Follow these guidelines to ensure you don't get into hot water with your patient -- not to mention CMS.

As for which plan you should report your provider's services to, you'll base your decision on why the patient is in your office. The key factors are the patient's chief complaint (CC) and history of present illness (HPI).

"You should bill the medical plan if your complaint/diagnosis is medical, and vision if the patient came in for a routine eye exam and your diagnosis is for a routine eye exam," says Vi Ballensky, administrator for Inland Eye Center in Spokane, Wash.

Example: A patient arrives complaining of blurred vision. Your ophthalmologist finds that cataracts are causing the blurriness. Report the office visit to the patient's medical insurance with the appropriate eye exam code (92002-92014, Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program ...), and link it to the appropriate cataract code (366.xx).

As a secondary diagnosis, report 368.8 (Other specified visual disturbances [blurred vision NOS]). If, however, the physician finds no cataracts or any other condition causing the blurred vision, report 368.8 as the primary diagnosis.

A patient sees your ophthalmologist for a routine eye exam and has no complaints. How should you code in this case, and which plan should you submit your claim to?

You'll still code according to why the patient is there. If the patient comes in with no specific complaint, but your ophthalmologist diagnoses a medical problem, report the routine visit as the primary diagnosis and the medical condition as the secondary diagnosis. Bill that visit to the patient's vision carrier.

Check your codes: Many vision plans specify that you use HCPCS codes S0620 (Routine ophthalmological examination including refraction; new patient) and S0621 (... established patient) for a routine exam. Other plans may want the general ophthalmological services CPT codes 92002-92014. For example, Medicare does not accept the "S" codes, but many Blue Cross/Blue Shield plans use them. So check with your individual carriers to be sure which code set you should use.

Tip: Vision plans are never secondary, says Mary B. Hill, CPC, specialty associate at Henry Ford Ophthalmology in St. Clair Shores, Mich. Ophthalmologists see patients for either a medical problem or routine vision care, she adds. "If the diagnosis falls in the range of 367.xx, then most carriers consider them to be routine vision services."

Bonus: There are times when you should bill both the patient's medical plan and vision plan. "Our office has billed some visits to both medical and vision plans and gotten paid the contracted amount by both," says Carolyn M. Osborne, who handles patient accounts for William B. Shannon, MD, in Gastonia, N.C.

Caution: Only report to both plans when the carrier has instructed you in writing to do so. Also, when determining the service level for the problem visit, do not include physician work for glasses/contact lenses.

You shouldn't have a problem reporting noncovered services to a patient's secondary plan (for example, refractions, contact lens fitting, etc.), but you shouldn't submit an E/M code and/or an "eye" code to both of the patient's insurance plans unless instructed in writing to do so by both plans.