Ophthalmology and Optometry Coding Alert

When you are asked to examine a patient on a consultation basis, and you need to perform a procedure listed on special ophthalmological services, you probably wont have any problems with Medicare. Special ophthalmological services include 92081 (visual field examination), 92060 (sensorimotor examination), 92100 (serial tonometry), 92020 (gonioscopy), and 92065 (orthoptic and/or pleoptic training). Refractions are special services too, but they are in an entirely different category when it comes to reimbursement. They are never covered by Medicare and if other payers cover them at all, it is usually as part of separate vision plans. In any event, a primary care physician is highly unlikely to specify serial tonometry or any of the other special ophthalmological procedures on an HMO referral form.

While Medicare will not object to paying for special ophthalmological services (except for refractions) along with consultations, you may well have problems with HMOs or PPOs, who dont feel that you should get paid for anything but the consultation. What these commercial insurers believe is that the requesting physician has asked for a consultationand only thatand unless the requesting physician has also askedspecificallyfor other procedures, well, theyre just not covered by the request for a consult.

Some practices have found that its better to deal with this problem ahead of time, rather than having to resubmit claims, write off charges, orthe most difficult task of alltrying to get a retroactive request form for the precise procedures performed.

1. Consult request should contain symptoms. One key is to make sure the primary care physician (PCP) lists all of the symptoms on the referral form, says Bonnie Weber, office manager for Hawthorne Eye Associates, a two-ophthalmologist practice in Winston-Salem, NC. The reason that the primary care doctor is sending the patient to you for your opinion has a lot to do with how easy it is to get paid for the extra services, Weber reports. For example, if the patient is having double vision, and the primary care physician writes that down, the insurance company will know that more needs to be done than just a consultation for you to form your opinion.

2. Second referral form is sometimes necessary. Bobbi Bachman, billing and insurance supervisor for Wyomissing Optometric Center, a two-optometrist practice in PA, agrees that listing the symptoms is important. But even so, she says, sometimes its necessary to send the patient back to the PCP for an additional request. If we diagnose a patient with a certain problem, we may have to send the patient back to the primary care physician for another request for a consult that specifies the additional services we deem need to be done, she says.

3. Calling the PCP and the insurance company. This isnt a very popular solution, because it is so time-consuming. But its worth it if the alternative is knowing that your claim is going to be denied. Its especially valuable if you can train the primary care physicians you work with regularly to be as specific as possible on the referral forms, our sources say. We do lose a lot of time and money calling the PCP, and the insurance company, says Bachman. Sometimes we have to go through each three or four times. Add to this the tendency of PCPs to only issue referral forms on certain days, and you have a potentially cumbersome process. Meanwhile, the patient is on your premises with the initial referral form and an appointment made in good faith.

The key to working this out correctly is, again, the symptoms, says Bachman. In fact, when PCPs try to put a diagnosis, instead of just listing the symptoms, there can be more problems. Three out of four times when PCPs put a diagnosis down on the referral form, its incorrect, says Bachman. Sometimes the form says the patient has glaucoma, but its wrong. Then, Bachman has to ask the PCP to fax a new referral form over so that the patient can be seen right away. And its important to keep calm throughout this annoying process. The patients dont understand what the fuss is about, says Bachman. They think they have a perfectly good referral form.

Weber agrees that the biggest problem with getting paid for special ophthalmological services along with consultations is incorrectly filled-out referral forms. Some doctors will fax us a new referral form, and some will say we can just draw a line through something or circle something, the office manager says. But most referral forms automatically include lab and x-ray work, and this helps us get covered for those types of services at least.

The only time Weber knows she will not get paid for special services in addition to a consultation is when those services are simply not covered, which usually occurs with 92015 (determination of refractive state).

4. Savvy receptionists save time. It helps to have a receptionist who is very alert to the possible problems of referral forms, says Jody Gustafson, billing clerk for the Erie Eye Clinic, a two-ophthalmologist, one-optometrist practice in Erie, PA. Our receptionists look very closely at each referral as soon as its presented, she says. If it isnt specific enough, shell call the PCP and get a corrected referral. One common problem, says Gustafson, is PCPs sending over referrals with only eye exam written on them. Its usually easy to explain that more is needed, and why.

5. Patient should sign a financial agreement. Regardless of what the referral form from the PCP says, Gustafson believes every patient should sign a financial agreement before the consultation. This agreement should say that if the insurance company will not pay for the visit, the patient bears the responsibility.

6. Medicare HMOs are fussy. Although Medicare itself doesnt have a problem with consultations and special ophthalmological services on the same day, Medicare HMOs often do, explains Gustafson. The Medicare HMO says we can only do whats on the referral form, the billing clerk explains. So if a patient comes in and decides to go ahead with cataract surgery, and wants an A-scan that day, we need to call the PCP and ask if its okay. If the PCP approves the A-scan over the telephone, saying a referral form will be faxed, the ophthalmologist will go ahead and do the A-scan, says Gustafson. The commercial PPOs, on the other hand, give participating ophthalmologists much more leeway. They are very open with us, she says. Once we have the referral, we have 60 days to do what we want.