Ophthalmology and Optometry Coding Alert

Some patients who come into the office for an eye exam deny they have vision problems. Ophthalmologists should determine the medical complaint by taking the patient history and thoroughly documenting it to get paid for these visits and to avoid fraud.

If you bill Medicare for an eye exam 92002, 92004, 92012 or 92014 you need to have documentation that supports the service as reasonable and necessary (just as you do for any claim). If the patient comes to your office and says, I need glasses, you must proceed very carefully in the history to find out if there are any medical problems, and you must document carefully as well. Failing to take a good history could mean that you cant bill Medicare for the exam because it will appear to be a routine service, and you will have to bill the patient. And failing to document well means that if you are audited you may have to refund the fee, pay a fine or submit to constant audits.

But the problem is that many patients are in denial about their vision problems. If they insist that they need a routine check-up for glasses and that they dont have any problems including vision problems you cannot bill Medicare for the visit, regardless of what you find in the exam. This is because Medicare has a long-standing national policy that the reason for the encounter determines reasonable and necessary services. This may happen when a Medicare patient comes in and doesnt want to admit that he or she might have a cataract, and so denies any vision problems at all. Following is an example:

Scenario: A patient comes in with 20/100 vision that cant be improved by any amount of refractive correction. Yet the patient has no complaint at all, merely stating, I just need a check-up to see if I need new glasses. Subsequently, a cataract is found. But with no complaint in the chart, there is no way that visit can be billed to Medicare. If the patient didnt complain, the patient pays, says Patricia Kennedy, COMT, associate consultant at Corcoran Consulting Group, a San Bernardino, Calif.-based ophthalmology coding and reimbursement consulting firm. Thats why, when training technicians, I tell them to leave the history blank until they start the refraction. Then, you can say, You did have 20/30 vision, now you have 20/100, are you having any problems? And the patient may, at that point, say, Well, I did notice the other day that I couldnt see the golf ball after I hit it. And there, explains Kennedy, is the medical necessity. Medicare will look for documentation of impaired daily living activities in the history as the indicator for a reasonable and necessary service.

Tip: If you saw a cataract six months ago in an established patient and asked them to come back, even if they dont have a complaint, you can bill for a cataract evaluation, says Kennedy. Its legitimate to monitor a patient for an ongoing disease. If it is a new patient with no disease, however, the visit is tantamount to screening, unless there is some kind of visual complaint.

Playing the Psychologist

The key to documenting medical necessity is to break through the patient denial, which requires playing the role of a psychologist. The denial is based in very human fears, notes Kennedy. After all, if a patient needs glasses, thats fine. But if its a cataract, that means surgery. In addition, people have an inherent tendency to deny the aging process, a fact with which physicians are very familiar.

Ron D. Frame, OD, an optometrist who practices with the nine-physician Optometric Physicians of Parkersburg in W. Va., agrees. I try to ask leading questions that cant be answered with a yes or no. And I also try to reassure them about whats normal. One of the most common problems that patients deny is cataracts, he says. To cut through this denial, Frame asks the patient about night driving. Everyone with cataracts has a problem with night driving, he explains. Its not necessarily that they cant see well in general, but just that the headlights create a blinding glare, so they stop driving at night. Usually, they still drive during the day, and their other activities are unchanged. It seems easy to deny that they have a problem. I ask, Are you still driving at night as much as you used to? says Frame. Everyone with cataracts says No. Frame then further explores the reason why, which may be due to glare. He tells the patient that there are tints that can be put into glasses to help with the glare this is before the physical examination, but he already has documented in the history that there is a complaint about less night driving due to glare.

Then Frame moves to the physical examination, and, if cataracts are there, he explains that to the patient. I see a cloudiness in your eyes, he says, and goes on to tell them they have a cataract. I say, Its not a disease, its a condition. Your hair turns gray, your back starts to hurt and your lens turns cloudy. The patient usually responds with, Yes, my hair is gray! And the diagnosis suddenly seems easier for the patient to deal with. But the key is not in the physical examination its in the history. That is where the complaint must be documented.

Regardless of whether the patient is found to have cataracts upon examination, if there isnt any patient complaint documented, there should be no reimbursement from Medicare for the visit. If you submit a claim with the cataract diagnosis, but without a patient compliant, are paid because of how you billed the diagnosis and are later audited, you run the risk of being charged with misrepresenting a non-covered service as a covered service.

Refractions Not Covered by Medicare

Under no conditions will you ever be reimbursed by Medicare for the refraction part of the visit. Its always a non-covered service by Medicare because its routine, says Marie Stamper, CMM, office manager for Ward Eye Center in Homosassa, Fla. Since the inception of the Medicare program in 1965, refraction has been classified as a routine service. Therefore, any refractive diagnosis the 367.x series of ICD-9 codes is routine and non-covered, she explains. Medicare requires that you separate the refraction from the visit. So if the patient has a complaint, you will get paid for the medical part of the visit, but not for the refraction. The refraction is always the patients responsibility.

All exams are driven by the chief complaint, explains Stamper. This means that as long as the patient has a complaint, you can bill for the exam. If the patient comes in complaining of headaches, for example, you can bill an office visit as well as 92015 (determination of refractive state). As long as the patient has a complaint, you can bill Medicare for the medical part of the exam, says Stamper. But you have to bill the patient for the 92015.

What if the complaint is related only to getting glasses? Then, reimbursement for the office visit will depend on how the documentation of the complaint is done, says Stamper. If a patient complains about vision difficulty, then you need to ask more questions, such as whether the patient was ever evaluated for cataracts, or has a family history of glaucoma or diabetes. You must be very chief-complaint conscious, Stamper says.

So, what is the bottom line? If the patient has a vision complaint, is the office visit covered if the patient has cataracts? This is a somewhat local policy issue, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based compliance, coding, and reimbursement consulting company. Some Medicare carriers wont pay for a blurry vision diagnosis, for example, whereas others will. Technically, because blurry vision could be a diagnosis associated with many medical conditions and because the doctor cant know the blurry vision is purely refractive in nature, there are reasonable and necessary grounds for the visit.

If, however, there is no medical condition found on examination and the problem is purely refractive, the patient should be held responsible for the examination charges as well as the refraction, says Roberts. In an audit, such a service would be considered routine. You need to keep digging to get as much medical justification as possible into the history. If the patient insists there is no medical complaint or change in daily living activities related to their vision, then an explanation should be given to them that the visit will not be covered by Medicare in the absence of a medical reason for the visit. The patient should sign an advance beneficiary notification (ABN) form. By signing the ABN, the patient accepts responsibility for paying.