Ophthalmology and Optometry Coding Alert

Question: For refraction, should I report a 992xx or 92xxx exam code?

Maine Subscriber

Answer: By definition, codes 992xx (Office or other outpatient visit ...) and 920xx (Ophthalmological services: medical examination and evaluation ...) do not include refraction. Some practices charge for refraction using 92015 (Determination of refractive state); however, most insurance companies will deny this code unless the patient has a vision plan that will pay for the refraction.

Sometimes, the exam is billed to the health insurance and the refraction to VSP or the patient's vision plan. Otherwise, the patient will need to pay for the refraction.

In the case of 920xx exams, some practices have tried to go around refraction noncoverage by submitting a 920xx eye exam procedure code with a refractive diagnosis code. Occasionally, these attempts are successful, but often they fail.

Example: Submitting a claim for 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits) with 367.1 (Myopia) is not proper coding and, therefore, will result in a claim denial.

Medical billing rules are very different from vision plan rules. The wisest move for insurance verification is to verify both vision and medical plan benefits prior to the patient's visit.

If a payer determines that a service is noncovered, the patient is responsible for payment. However, if a service is considered "bundled" into an E/M or eye code, you are not allowed to collect this payment from the patient.