Ophthalmology and Optometry Coding Alert

Medicare doesnt pay for refractions; some private policies do, but most dont. How can ophthalmologists get paid for doing refractions? We asked three coding experts for solutions to this ongoing problem. The code for refraction is 92015.

Part of the Exam

One answer is not to bill refractions at all, says Theresa Collins, insurance supervisor for Suncoast Eye Center, a seven-ophthalmologist, three-optometrist practice in Hudson, FL. With Medicare patients, we dont charge separately, says Collins. You know it wont be paid anyway. Collins uses the E/M services codes, not the eye codes.

Several people we spoke to indicated that they are billing the refractions separately. However, our experts warn that this could cause future problems in a Medicare audit. In Medicare, the refraction is never considered part of the exam. It doesnt matter whether the refraction was done for purposes of prescribing glasses or for medical diagnostic purposes; its not a covered Medicare benefit, period. And, if you include refraction services on your office visit claim, and are audited, the auditor will tell the carrier to deduct the amount for the refraction from the bill, which is usually 20 percent.

However, many HMOs and PPOs do consider a refraction included in the exam.

Note: If a Medicare patient comes in just for an eye exam, you cant bill Medicare for an office visit or anything else. We have to bill the patient then, Collins says.

Collecting From the Patient

The best solution is to collect payment for the refraction from the patient. With commercial HMOs, Collins does charge the patient for the refraction part of the office visit, if vision exams arent covered. The vision exam is separated from the other procedures, and the patient must pay. The key to making this work is collecting the money right away, she says. Yes, theres a PR problem with collecting this money, the insurance supervisor acknowledges. But the PR problem is much worse if you send a bill. The best way to handle this is to collect the fee at the desk the day the patient is seen.

We have the receptionist explain it to the patient on a face-to-face basis, explains Collins. But when it comes in the mail, the patient feels the insurance should pay for it. Then, it becomes a long drawn-out problem, with telephone calls back and forth and escalating annoyance on all sides.

If its done on a face-to-face basis, patients seem to understand, she says. If they have questions, we can explain that their insurance doesnt cover eye exams. Explaining this on the telephone after a bill has been sent is much more difficult. Then, its a billing situation, and the patient is defensive.

Mei Lam, billing manager for New York Eye Center, a four-ophthalmologist practice in New York, NY, acknowledges that patients dont like to be charged for refractions. But when you charge them for anything, they dont like it, says Lam, whose practice has many Medicare and Medicaid patients. You just have to explain why you cant bill their insurance.

Evan Malloy, business coordinator of the Eye Center at Medical Associates Health Center, a six-optometrist, two-ophthalmologist practice in Menomonee Falls, WI, also takes a hard line when it comes to collecting for refractions. If thats all they want, we tell them Medicare wont cover it, so they have to pay in advance, he says. The patient is told this before he or she sees the doctor. If the patient is aware that the refraction isnt going to be paid by insurance, and doesnt want to pay, then he or she can decide to go to Sears or Wal-mart instead -- where the exam may be less expensive, he says.

Tip: Some coders suggested that you can use a 99211 office visit along with an vision exam. You cant. If you are doing a refraction, 92015 is the code you must use.
Otherwise, you are misrepresenting the refraction as an office visit, and misrepresentation of services is a classic fraudulent billing citation. You cant bill an vision exam and an E/M services code in the same visit. If youve been doing it and getting away with it, its because you havent been audited.