Ophthalmology and Optometry Coding Alert

A patient presents for what you expect will be a routine vision exam, but then you find 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 plans?

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

Base your decision on which plan to bill on the reason the patient is in the office. The key factors are the patient's chief complaint (CC) and history of present illness (HPI).

Bill the medical plan if the complaint or diagnosis is problem related, and bill the vision plan if the patient came in for a routine eye exam and the diagnosis is for a routine eye exam, say experts.

Example: A patient arrives complaining of blurred vision of recent onset. The case history reveals no history of amblyopia or other longstanding problem. The 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 ophthalmologist finds no cataracts or any other condition, including a refractive error, 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 the chief complaint as to why the patient presented to the office for care. If the patient presents with no specific complaint, but the 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. The diagnosis code should relate to the chief complaint -- so when the patient has no complaints, the visit is routine unless additional significant workup was necessary for problems found during the encounter.

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 BlueCross BlueShield plans use them. So check with your individual carriers to be sure which code set you should use.

Experts say: When the ophthalmologist does find a medical problem during a routine exam, he might consider having the patient return on another day for any further tests, rather than convert the exam from routine to medical. A patient who presents for a routine screening with a $20 copay may be confused and upset when he sees a bill for a problem related medical eye exam -- even if his out-of-pocket expenses are the same.

"It's the doctor's call on that situation, but think about how your patient may perceive it," advises David Gibson, OD, FAAO, an optometrist practicing in Lubbock, Texas. "Remember, the average patient does not understand the difference between a routine eye exam and a problem related medical eye exam. Some patients are very protective of their 'annual free' routine eye exam and may be upset if they didn't expect an office visit requiring a patient copay, co-insurance or non-payment due to deductible."

Strategy: If appropriate, you may be able to:

• provide the routine screening as requested by the patient,
• discuss the need for additional care for any problems discovered during the exam, and
• bring the patient back for a future visit that will allow adequate visit time and in consideration of the patient's choice to elect medical care with the same or a different provider.

Example: A patient with no complaint comes in for the routine eye exam that his vision insurance provides. The ophthalmologist discovers glaucoma. Bill the patient's vision insurance with S0620 or S0621, and link it to V72.0 (Examination of eyes and vision). As a secondary diagnosis, report the glaucoma (365.xx).

If there is a follow-up exam later, the medical condition will be the primary diagnosis and the bill goes to the patient's medical insurance.

When the patient returns for further diagnostic tests -- such as 9208x (Visual field examination, unilateral or bilateral, with interpretation and report ...) and 92020 (Gonioscopy [separate procedure]) -- link the codes to the glaucoma diagnosis, and submit the claim to the patient's medical insurance.

Bonus: There are times when it may be necessary for you to separate routine vision care and problem related ophthalmic care and bill both the patient's medical plan and vision plan. Caution: Report to both plans only when the carrier has instructed in writing for you 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 non-covered services to a patient's vision screening plan (for example, refractions, contact lens fittings, etc.), but you shouldn't submit an E/M code (99201-99215) and/or an eye code (92002-92014) to both of the patient's insurance plans unless instructed in writing to do so by both plans.

"In some cases of medical and routine plans together, you can bill the problem related medical care to the patient's health insurance plan and a refraction only to the routine vision screening plan," says Gibson.

Catch: You should not bill a full exam to both companies, Gibson notes; doing so would be interpreted as double billing. "In some cases, the patient's medical policy plan is not aware of an employer-arranged routine plan that is separately provided as part of an employee's benefits," he says. "Again, check with the routine vision plan and/or medical plan payer for guidelines."