Ophthalmology and Optometry Coding Alert

Use these tips to smooth the conversation with your patients.

Performing refraction services can sometimes create a bit of a catch-22 situation at your practice: The eye care specialist has to use refraction to pinpoint a patient’s eyeglass prescription — but Medicare and many other payers won’t reimburse you for refraction. Patients are left with the bill and the office staff is left feeling uncomfortable about the unpleasant patient run-in.

However, if your practice prepares ahead of time, you can help ease the conversation with patients so there are no billing surprises and everyone is happy.

Non-Covered but Frequently Performed

You are likely familiar with CPT^® code 92015 (Determination of refractive state), which is commonly billed after the physician works to determine the most accurate eyeglass or contact lens prescription. Because neither the ophthalmological services codes nor the E/M codes include refractions, some practices charge for refraction using 92015. Many third-party medical insurers consider the service non-payable. For patients with a separate vision plan, refractions are typically covered, often as part of the annual vision exam.

In black and white: CMS says in Chapter 16 of the Medicare Benefit Policy Manual, “Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.” Many private payers follow Medicare’s lead in this regard and consider refraction a non-covered service.

Certain vision plans will include a provision for routine vision care, which can cover the exam and refraction and provide for a materials benefit as well. If the patient also has a vision plan, find out what the coverage details are, but remember this distinction: Vision plans are not insurance — they are a discounted fee-for-service plan that provides for an exam/ refraction and materials or contact lens benefit. Typically, it is a one-time per year benefit.

Read on for five simple tips that can help you find your way to better patient relationships involving refraction.

1. Discuss With Patients Before You Perform

Despite the refraction non-coverage situation being a longstanding Medicare policy, many patients are shocked to hear that they’ll have to pay for refraction. Therefore, you should discuss the non-coverage with patients before you perform refraction. No patient should leave your office and be presented with a bill for refraction that stops them in their tracks. They should always be aware of the cost and the non-covered status of refraction before agreeing to the service.

2. Explain What Refraction Does

Patients may understand what refraction is if you explain it in plain English. Let them know that the service allows the doctor to determine if they need glasses; and if so, which prescription suits them best. If they say they’ve never heard of such a service, you can let them know “This is when the doctor asks, ‘Which is better, one or two? Two or three?’ and so on.”

3. Consider an ABN

As a refresher, an advance beneficiary notice (ABN) is voluntary for items that are statutorily excluded (never covered by Medicare, such as refraction) or do not meet the definition of a Medicare benefit. But because some Medicare patients don’t know the refraction is not a benefit, the ABN may be a good idea to help explain it. If they sign the ABN, it spells out in detail that refraction is not a benefit and that they will be responsible for the charge if they choose for the doctor to perform refraction.

4. Create a Refraction Policy

In lieu of an ABN, you can ask new patients to sign a refraction information statement along with your other financial policies. The statement can inform the patient of what the service entails, the fact that Medicare and most other insurers don’t pay it, and your office’s standard charge for the service. It could also say that the eye care physician will only perform refraction if they believe it would contribute to the health of the patient’s vision, and that the patient would be responsible for the charge if he or she decides to proceed with the service.

Patients can sign and date these forms, so if they ever do get charged for refraction and seem confused, you can show them the statement that they signed and remind them of the reason for the charge. Many practices choose to introduce the form for each refraction. “Patients do not remember what they signed at previous visits,” says Mary Pat Johnson, COMT, CPC, COE, CPMA, senior consultant with Corcoran Consulting Group. “Medicare precludes the use of a ‘blanket’ ABN. Commercial insurers may have a similar guidance.”

5. Determine Whether to Submit the Code

When billing the payer, you aren’t required to submit 92015 on your claim form if you know it is non-covered, but you can do so to track your services. If you report the code to Medicare, ensure that you append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) to the code so the Medicare administrative contractor (MAC) will know that you aren’t expecting payment for the service.

Of course, the patient may have a vision plan outside of their medical insurance that does pay for refraction. If you don’t know about a vision plan at the time of service and the patient calls you later with the details, you can bill it to the plan. If you are reimbursed for refraction from the vision plan later, be sure to pay the patient back for any charge they paid you for the refraction.

Keep in mind, however, that the vision plan often pays for a comprehensive exam, which includes the refraction. “They may not reimburse for the refraction alone [92015],” Johnson says. “Additionally, billing the vision plan and the medical plan for the same date of service is not allowed by all payers. Both plans cannot reimburse an office visit code for the same encounter. That is ’double-dipping.’”