Ophthalmology and Optometry Coding Alert

Question: When the patient has workers’ compensation and Medicare, and workers’ comp doesn’t cover the whole visit, can we bill Medicare for the balance?

Codify Subscriber

Answer: Yes, you can. The workers’ compensation insurer will always be the primary payer, but “If workers’ compensation insurance denies payment, and you give Medicare proof that the claim was denied, Medicare will pay for Medicare-covered items and services as appropriate,” CMS says in its “Medicare and Other Health Benefits: Who Pays First” document.

For example, suppose a Medicare patient is working at a warehouse part time loading boxes. They get a piece of sawdust in their eye and report to the ophthalmologist. The claim is sent to the workers’ compensation insurer, which denies paying for the service. The eye care practice can send Medicare the claim along with a copy of the workers’ comp denial. Medicare will pay the eye care physician for the Medicare-covered items and services administered as part of the service, but the patient has to pay for any services non-covered by Medicare.