Ophthalmology and Optometry Coding Alert

Question: I am bothered by the fact that some insurance companies -- namely, MAMSI, Optimum Choice and MD IPA -- ask providers to file routine eye exams with 92015 (determination of refractive state). In one case, the doctor found 367.1 (disorders of refraction and accommodation; myopia) during a comprehensive dilated exam, which the patient's insurance allows. But the exam was done because of a corneal scar. These payers want to bundle the charges for the exam into 92015. But that's not the service we performed. We did a comprehensive examination. What can we do?

Florida Subscriber

Answer: The payer in this case is using CPT codes inappropriately for claims processing. Unfortunately, payers other than Medicare can set up any policy they want for reimbursement of services. There is no national agency overseeing their activities in the way that the Centers for Medicare and Medicaid Services (CMS) oversees Medicare and Medicaid.

This insurance problem has many variations. Some payers allow a routine eye examination to be billed with 92014, but bundle 92015 into it and require a diagnosis of V72.0 (special investigations and examinations; examination of eyes and vision) or one of the refractive-error diagnoses. Such payers then allow medical visits to be billed only with one of the E/M codes and a medical diagnosis. If the claim is submitted using 92014 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) and a medical diagnosis, it is denied. It is also denied if the claim is submitted with an E/M code and either V72.0 or one of the refractive-error diagnoses as the primary diagnosis.

Changing payer policy is difficult. First, you should take the payment policy issue up to a higher level of the payer administration. Set up a meeting (phone or in person) among one of your physicians, a coding representative, and the payer's medical director. Contact your state ophthalmological association, which may be interested in getting behind your effort. Do your research and be prepared with your arguments.

One possible argument rests in the contract for payment that you have with the payer. If that contract stipulates that they pay based on RBRVS unit values or another unit-value scale, then you can argue that there are no unit values in 92015 for performing an examination of the visual system.  

Likewise there are zero unit values of the service for refraction in the eye examination codes, 92002-92014, or the E/M codes for visits. If reasoning fails, let them know that you are prepared to take legal action for breach of contract.

Also, find out what the payer marketing literature says about the coverage the patient can expect for routine vision care. If their marketing promises a routine examination of the whole visual system, or implies that this is the case, suggest to them that they are using false and misleading statements in their marketing if they only pay for a reaction. Suggest that the state agency that oversees the medical insurance industry will likely be very interested in this. Make sure you know which state agency has this power and use the name of that agency. If you can find out the name of the person who heads the agency, use that name in the conversation, too. Always try calm reasoning first. If they are entrenched in their position, talk about possible legal action that you are prepared to take or state insurance agency involvement. Never make a statement that you are not fully prepared to follow through on.

Obviously, trying to change the payer policy is going to take time and effort. This should be a business decision and not just one of principle. Evaluate the number of denials you have with this payer annually as a result of its policy. If the potential gain won't outweigh the cost, consider dropping the issue unless the expense can be shared by others with the same problem. Seek legal counsel before you contact other offices about joining the effort. You must steer clear of providing the payer with the ability to claim you are interfering with its other business contracts.

  -- Answers to "You Be the Coder" and "Reader Questions" contributed by Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.; and Lise Roberts, vice president of Health Care Compliance Strategies in Jericho, N.Y.