Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist evaluated a patient complaining of blurry vision and diagnosed them with bilateral myopia after an exam that included refraction. We reported the appropriate E/M code (99203) and H52.13 for myopia, but the claim was denied. Where did we go wrong?

Kansas Subscriber

Answer: The denial was likely due to the code you used to report the visit. Depending on the payer, myopia may not be a covered diagnosis for the group of evaluation and management (E/M) codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Refractive errors may be covered diagnoses for the family of eye visit codes 92002-92014 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program …) and/or the following HCPCS Level II codes:

• S0620 (Routine ophthalmological examination including refraction; new patient)
• S0621 (… established patient)

You should use 92015 (Determination of refractive state) to code the refraction, as appropriate.

Note: Medicare considers refractions a non-covered service. Because it’s always non-covered, an Advance Beneficiary Notice of Non-coverage (ABN) is not required. Thus. the service is considered the patient’s responsibility. Commercial payers’ coverage of refraction may vary. Some will pay with a vision diagnosis, others will pay with a medical diagnosis, while some will bundle the refraction with the office visit. Best practice is to carefully review the commercial participating provider contract for refraction coverage.