Ophthalmology and Optometry Coding Alert

Question: I always seem to have trouble when patients come in for a yearly diabetic eye exam. This exam is a Medicare-covered benefit and should not be subject to a deductible or a copay. I filed the claim with CPT^® code 92014 for the comprehensive exam and ICD-10-CM code E11.9 for the diagnosis since the patient has Type 2 diabetes.

Humana paid the claim, but the patient ended up owing a copay. I’m having trouble finding specific guidelines on the Medicare site. Am I using the wrong codes? Can you give me any tips?

Minnesota Subscriber

Answer: You are correct to report 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) for the yearly diabetic eye exam, provided you have the documentation to support it as a comprehensive exam, according to your payer’s requirements.

And you were correct to report ICD-10-CM E11.9 (Type 2 diabetes mellitus without complications) as the diagnosis code, provided there were no new diabetic complications.

Co-pay: In its guidance on yearly diabetic eye exams on the Medicare.gov site, Medicare indicates that in Original Medicare, patients pay “20 percent of the Medicare-approved amount for the doctor’s services and the Part B deductible applies.” This Medicare-approved amount for the exam is the amount Medicare allows for the service, and, according to Medicare, “may be less than the actual amount the doctor charges for the service” and that the patient “is responsible for the difference.”

Limits: For a non-participating provider, the provider may bill the patient up to Medicare’s Limiting Charge only. For the participating provider, the provider may only bill the patient up to Medicare’s allowance and for the non-covered services, such as refraction.

In your case, the Medicare Advantage Plan is holding the patient liable for a “copayment” rather than a “coinsurance.” This patient has a Medicare Part C (or a Medicare Advantage Plan) that is taking the place of traditional Medicare for services provided by a physician in an outpatient setting.

Your office does not bill traditional Medicare Part B. You will bill the Medicare Advantage Plan. Although many of the Medicare Advantage Plans follow Medicare guidelines for medical necessity, etc., they often have their own provider payment and patient responsibility methodology.

Do this: If you are questioning the patient liability, it is best to access the patient’s benefits on the insurance company’s website for verification.

Resource: To read Medicare’s annual diabetic eye exam guidance, see www.medicare.gov/coverage/eye-exams-for-diabetes.