Ophthalmology and Optometry Coding Alert

To get paid for refractions ophthalmology practices should have the patient sign a waiver, understand commercial policy and understand patients rights.

Its no secret that Medicare wont pay for refractions, code 92015 (determination of refractive state). As for commercial plans, many times coverage does seem secretive. Patients often dont even know what their own coverage is. As one biller puts it, Refractions are a jungle.

But this doesnt mean you cant get paid for refractions. Although, the patient has to pay most of the time, there are rules for how this is to be done. Here are some tips:

1. Have the patient sign a waiver form. Although a waiver of liability form is not required by Medicare for services that are always non-covered, many practices have the patient sign one anyway as a way of informing them in advance that the refraction will not be covered by Medicare, says Lise Roberts, vice president of Health Care Compliance Strategies of Syosset, N.Y . This is an often misunderstood area, explains Roberts. Patients do not have to sign waivers of liability when a service is always non-covered, she says. Waivers are only required when a service is sometimes covered by Medicare, but in this instance, billing wont be covered.

Refractions are never under any circumstances paid by Medicare. They are not a benefit of the Medicare program. This is clearly stated in the Medicare Beneficiaries Handbook which the beneficiary receives when they first enroll in Medicare Part B, notes Roberts. With Medicare, you can only bill patients if its a non-covered service.

Because the service of refraction is not a benefit of the Medicare program and is always not covered by Medicare, you are allowed to bill patients directly for the refractions, Roberts says.

Most Medicare patients are getting this message now, says Jeri Groesch, billing clerk for South Hills Eye Associates of Pittsburgh, Pa. We know ahead of time if the patient is on Medicare, and we have them sign the waiver.

2. Determine commercial policy. Commercial, PPO and HMO plans are different. We dont know how the insurance works until the patient is here, says Groesch. The front desk clerk must ask. Some patients know if they have vision coverage, but some just think they do. And some dont know at all. If the patient doesnt know whether they have vision coverage, as a courtesy, we will file the claim and wait for the EOB, says Groesch. When it comes back and the refraction isnt covered, we collect the fee from the patient.

This can be tricky, though, because sometimes the payer denies payment because they consider the refraction included in the eye exam code or the E/M code, notes Roberts. If it is a PPO or HMO plan that does this, then you may have to write off the refraction charge to maintain your contract to be a provider under that plan. For patients of commercial plans who know up front that vision care isnt covered, the practice collects the refraction fee at the time of the visit.

3. Take caution when taking the hard line. Some patients balk at paying for the refraction. They dont understand how their insurance works. Such patients often refuse to pay for the refraction. Although some practices take a hard line with these patients and refuse to release the patients prescription for the eyeglasses, this can actually be a violation of state law, says Roberts.

Readers are encouraged to make sure that there is no state statute in existence where they practice which requires that they give the prescription to the patient if the patient asks for it.

The best way to ensure that patients dont receive services for which they later refuse to pay, says Roberts, is to inform them in advance of receiving the service that they will be responsible for the bill if their insurance plan does not cover the service. This is another situation where it is a good idea to have the patient sign an agreement that they will pay for the service if it is not covered. A few patients may refuse the service under these circumstances. Most of these refusals can be reversed if there is a medical reason for performing the refraction that is explained to them.

Routine Eye Exams

Sometimes, a patient will say he or she wants a complete eye exam, but has no specific complaint. Medicare wont pay for routine eye exams without a complaint, notes Groesch. It is the patients reason for the encounter that determines whether a service is medically necessary and covered in the Medicare program. Routine services, defined by Medicare as any service that occurs in the absence of a sign, symptom, complaint or known diagnostic problem, are not a benefit of Medicare. Even if a disease process is discovered during the examination, if the recorded history does not reflect a sign, symptom, complaint or known diagnostic problem, then the service is not covered by Medicare.

This is why its so important for the technician to interview the patient carefully, to find out if there are any possible problems. Difficulty seeing at night, difficulty reading, difficulty performing detailed tasks like sewing, visual disturbances like halos or distortions in the vision all of these areas are pertinent to a chief complaint.

If a practice bills a service with a diagnosis found during the examination but there was no sign, symptom, complaint, or known diagnostic problem recorded in the history, the Medicare carrier will likely pay the claim even though they shouldnt, says Roberts. It represents a false claim under the False Claims Act. If an isolated claim like this were discovered during a Medicare audit, the money paid would be recouped. If a pattern of billing claims like this was discovered, then the Medicare carrier would turn over the case to the Office of Inspector General for investigation and prosecution under the False Claims Act.