Ophthalmology and Optometry Coding Alert

Question: Our patient’s vision plan covers either contacts or glasses annually, and she used it to buy contacts this year. But after she got home, they were uncomfortable because her eyes were so dry. Now she wants to get glasses but she is complaining that she’ll have to go out of pocket to buy them. Is there a workaround to this?

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Answer: Once she heads home with the contacts, chances are that you won’t have a workaround. You’re correct in saying that most vision plans cover either contacts or glasses—but not both. However, if you manage the situation up front, you may have better luck with future patients.

First, you should learn the patient’s coverage inside and out, but remember this distinction: “Vision plans are not insurance,” says Jerry Godwin, president of eye care consulting firm OMS in San Antonio, Tex. “They are a discounted fee for service plan that provides for an exam/refraction and materials or contact lens benefit. It is a one-time per year benefit.”

The patient may not realize what the plan covers and how much they can get with it, and that’s up to you to share with them. Explain what their out of pocket expenses are prior to the visit and let them know that their coverage won’t pay for both glasses and contacts if that’s the case. If you follow these steps, you should have smoother sailing. However, if you do encounter a situation like you have in your question, it’s possible that the issue stems from your provider and not your front office staff.

“The problem lies with the doctor not properly managing the patient’s condition and expectations,” Godwin says. “The doctor must educate the patient and advise them on a treatment plan to care for their condition. Glasses are a source of ‘treatment’ for the patient’s medical condition if they are not capable of wearing contact lenses.”

Since the doctor is the only person who can clinically determine whether the patient’s eyes are suitable for contact lenses, it’s up to him or her to ensure that the patient is aware of the best clinical treatment option at the time of the prescription.