Ophthalmology and Optometry Coding Alert

Question: Should I code for a refraction if a new prescription is not required?

Florida Subscriber

Answer: If the patient is Medicare, code the refraction 92015 (Determination of refractive state), but you are not required to submit the charge to Medicare. If you submit a claim for the work done that day as 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient), which does not include a refraction, Medicare will pay for the work (exclusive of the refraction), assuming it is medically necessary. The refraction is not included in the E/M or eye exam codes, which is why it is coded with 92015. Code the work performed, regardless of whether you prescribe eyewear, just as you would code an E/M service. Refractions are not a benefit of the Medicare program; the patient is responsible to pay for all noncovered services, including a refraction.