Ophthalmology and Optometry Coding Alert

Question: Our eye care clinician performed orthoptic training every two weeks for eight months in a 16-year-old patient and we reported 92065, which his payer covers. However, we’ve started getting denials. Can you advise why this might be happening?

Tennessee Subscriber

Answer: There are a few potential reasons why your payer may have started denying the visual training sessions, but the most likely assumption without seeing your documentation is that you potentially exceeded your insurer’s frequency guidelines.

Payers will have their own rules on how to collect for 92065 (Orthoptic and/or pleoptic training, with continuing medical direction and evaluation), but most insurers will only cover this service for a finite period.

For instance, Aetna’s policy notes that some of its individual plans exclude coverage for orthoptic training, but “Under plans with no such exclusion, Aetna considers up to 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency. Aetna considers vision therapy experimental and investigational for all other indications.”

So, if you performed the service twice a month for eight months, then you probably exceeded the 12-visit limit (if your payer’s policy is similar to Aetna’s and imposes such a limit).

Another possible cause would be that you performed the service for a non-covered condition. As indicated above, Aetna only covers visual training for convergence insufficiency (H51.11), so if you billed it for conditions such as myopia, visual field defects, nystagmus, or another condition outside of the H51.11 code description, then your payer may have denied the service for that reason.

Your best bet is to contact the payer directly and inquire about the reason for denial. Ask the insurer for a copy of its 92065 policy in writing so you can adhere to the coverage guidelines in the future.