Ophthalmology and Optometry Coding Alert

Question: Do I need a waiver for routine eye exams?

Wisconsin Subscriber

Answer: Medicare views routine eye exams the same way it views refractions: They are not covered because they are not a benefit of the Medicare program. Although you do not have to get a waiver, it is recommended anyway. The communication the patient receives from Medicare if a claim is denied can send him or her straight to the telephone full of anger at your practice. If the patient receives a denial due to your claim not being reasonable and necessary, you will have a hard time collecting from the patient because the denial will say: If your physician supplier did not inform you the service was not covered ... you are not responsible for payment.

Depending on the carriers claims-processing system, the patient should get that note when you use the V72.0 diagnosis code.

Even if you tell the patient when he or she comes for the visit that it may not be covered, and therefore the patient may have to pay for it, the patient may forget this when the Medicare denial comes. But patients tend to remember something that they have signed.

Also, collect payment on the date of service. Otherwise, you have collection costs even if it is just sending out the bill once. The only time we recommend waiting is when there is some doubt about whether Medicare will deny the claim as not reasonable and necessary or when patients have a secondary insurance policy that they believe will pay the service and you agree to bill the secondary policy and accept assignment on it.

As discussed in the article Dont Use Routine as the Reason for a Follow-up Visit, you can bill Medicare for an eye exam if it is not routine. The key is to use the correct diagnosis code when billing. If you submit with a refractive error code, such as myopia, the claim will be denied as not reasonable and necessary and patients will receive the notice stating that they may not be responsible for payment.