Improve Reimbursement for Consults and Special Services on the Same Date
Published on Thu Apr 01, 1999
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 [...]
