Ophthalmology and Optometry Coding Alert

Question: A Medicare patient comes in for a medical examination, and we also perform a refraction. If we report both but the refraction is rejected, should we then bill the patient's vision plan for the refraction?

Colorado Subscriber

Answer: Most vision plans are designed so that you bill either the medical plan or the vision plan not both. For a vision plan, you should usually report the ophthalmology service (92002-92014) only, which usually includes the refraction. You should link the eye code to a vision diagnosis, not a medical diagnosis.

Medicare understands that part of the visit might be medically necessary and part might not. For example, a patient presents for a new pair of glasses and also has itchy eyelids (373.00, Blepharitis, unspecified). You should bill the vision plan for the ophthalmology service, and Medicare for the appropriate-level E/M code (99201-99215) that represents the work involved in diagnosing and managing the medical condition. You can use two different codes, one for each payer, but do not double-bill the work. If you bill Medicare for the work involved in the anterior segment exam and the history-taking relevant to the medical problem, don't include that portion in what you report to the vision plan.

Medicare states that the total of the combined billing should not exceed a comprehensive visit code (E/M or eye exam). Bill Medicare for a low-level code, and bill the balance to the vision plan using a low-level code. For example, you might bill an intermediate eye exam (92002, 92012) to the vision plan, and a level-two E/M code (99202, 99212) to Medicare.