Ophthalmology and Optometry Coding Alert

When coding for refractions (92015), ophthalmology coders often get confused about the discrepancy between the Medicare Carriers Manual (MCM) policy and how to get reimbursed. HCFA admits that the MCM is out-of-date and plans to revise it accordingly. The old, inaccurate language states that providers must bill patients for refractions done at the time of eye exams (92xxx) or the carrier must deduct a portion of the providers fee.

Since 1997, when the local carrier policies for eye codes (92002-92014) emerged, refraction has not been included in the work for any of these codes. CPT makes it clear that 92015 (determination of refractive state) is not included in the eye codes. And refraction has never applied to the E/M codes.

A correction to this outdated version of the MCM is forthcoming, according to a letter from HCFA to the American Society for Cataract and Refractive Surgery/American Society of Ophthalmic Administrators (ASCRS/ASOA).

The revised policy will make it clear that ophthalmologists do not have to bill patients for refractions if they dont want to (although refractions will remain non-covered under Medicare).

The current, but inaccurate, MCM states that in an audit, an ophthalmologist could be penalized the amounts stated for not billing the patient for the refraction. This is no longer true.

HCFA Agrees with the CPT Coding Manual

ASCRS has been lobbying for more than two years to obtain this revision, which has yet to be put into the MCM, but which will be added in the future, according to a letter from Terrence Kay, director of HCFAs Division of Practitioner and Ambulatory Care, to ASCRS president Douglas D. Koch, MD. Koch had requested that HCFA clarify the current confusion about billing of refractions. Kay responded last fall by saying: We agree that the Medicare Carriers Manual provisions on refractions are out-of-date. Determination of the refractive state is listed as a separate code, 92015, which is not included in the definition of a comprehensive ophthalmologic service. HCFA agrees with the CPT coding manual.

The most recent MCM instructions on refractions were dated 1996 (B3 15054). The instructions state: Do not make fee schedule adjustments for ... refractions. If you receive a claim for a service that also indicates that a refraction was done, do not reduce payment for the service. HCFA already has made the reduction in the RVUs being provided to you.

Collect Up Front

Most ophthalmologists do bill patients for refractions. In fact, they say the best way to bill is to collect at the time of service. We have no problem collecting once its been explained to the patients, says Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care in Louisville. I dont know of any ophthalmologist who doesnt bill patients for them.

Some patients tell the ophthalmologist theyve never had to pay for a refraction before, Oyler says. She suspects that this is because the patient had previous refractions done by the optometrist, who billed the patient for the eyeglasses and the refraction together.

When to Get a Denial First

Sometimes, when the patient has secondary vision coverage, or whenever a patient requests that you file first, you must file for a refraction with Medicare before collecting from the patient.

Some insurance companies cover refractions under secondary policies, but they need to see a denial from Medicare before they will pay. Therefore, for some billing purposes, you should bill Medicare and receive the denial before the patient can file the claim with the insurance company covering vision benefits. Also, even if you believe Medicare will deny a service and you do not file secondary insurance for patients, if the patient asks you to file a claim for the refraction with Medicare, you cannot refuse. Medicare requires that a claim be filed (even for a noncovered service) if the patient requests it.