Ophthalmology and Optometry Coding Alert

Question: When we perform refraction, should we use an E/M code like 99212 or an ophthalmological services code such as 92002?

Rhode Island Subscriber

Answer: In most cases, neither code is appropriate, because the majority of payers won't reimburse you for refraction. In addition, if you report refraction using a code that suggests you're performing a different service, such as an E/M visit or an ophthalmologic service, you could face accusations of fraud.

In black and white: "Reporting screening, preventive or refractive error services with codes 92002-92014 is misrepresentation of the service, potentially to manipulate eligibility for benefits and is fraud," Blue Cross/Blue Shield of Rhode Island says in its policy. "If the member has no coverage for a routine eye exam or lens services, it is appropriate to inform the member of their financial responsibility."

The only code that actually describes refractions is 92015 (Determination of refractive state). Most payers, including Medicare, consider this a non-covered code. However, there are some vision insurers that will cover the service in some circumstances.