Ophthalmology and Optometry Coding Alert

Tip: Create a refraction policy to smooth the conversation.

Every eye care practice has experienced this situation many times: The physician performs refraction to pinpoint a patient's eyeglass prescription, and then the patient complains about receiving a service that the payer doesn't cover. Patients are left with the bill and the office staff is left feeling uncomfortable about the unpleasant patient run-in.

Fortunately, it doesn't have to be this way. There are a few steps you can take to stem difficult refraction conversations. Read on to find a few possible solutions to help smooth the path.

Non-Covered But Frequently Performed

In 2017, CPT^® code 92015 (Determination of refractive state) was billed on 13.42 percent of optometrists' claims, according to Medicare data. Because neither the ophthalmological services codes nor the E/M codes include refraction, some practices charge for refraction using 92015, even though many insurers consider the service non-payable unless patients have a separate vision plan that will pay for it.

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.

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.

Consider following these steps to ensure that patients are well-informed about the service:

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."

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.

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 he or she believes 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. (See our clip-and-save on page 43 for an example of what such a letter might look like).

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.

Determine Whether to Submit the Code

When billing the payer, you aren't required to submit 92015 on your claim form since it's 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 MAC will know that you aren't expecting payment for the service.

Of course, the patient may have a vision plan outside of his or her 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.