Optometry Coding & Billing Alert

When your patient has both types of insurance, who gets the bill? Let the reason for the visit decide.

A patient presents for what you expect will be a routine vision exam, but then you find cataracts. Should you still report the service to the patient's vision plan or to his medical plan because the optometrist found a medical problem? Or both plans?

Follow these guidelines to ensure you don't get into hot water with your patient - not to mention CMS.

Check CC and HPI for Clues

As to which plan you should report the provider's services, you'll base the decision on why the patient is in the office. The key factors are the patient's chief complaint (CC) and history of present illness (HPI).

Bill the medical plan if the complaint or diagnosis is medical, and bill the vision plan if the patient came in for a routine eye exam and the diagnosis is for a routine eye exam, say experts.

Example: A patient arrives complaining of blurred vision of recent onset. Your case history reveals no history of amblyopia or other longstanding problem. You find that cataracts are causing the blurriness. Report the office visit to the patient's medical insurance with the appropriate eye exam code (92002-92014, Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program ...) and link it to the appropriate cataract code (366.xx).

As a secondary diagnosis, report 368.8 (Other specified visual disturbances [blurred vision NOS]). If, however, you find no cataracts or any other condition, including a refractive error, causing the blurred vision, report 368.8 as the primary diagnosis.

No Complaint? Look to S0620-S0621

A patient sees you for a routine eye exam and has no complaints. How should you code in this case, and which plan should you submit your claim to?

You'll still code according to why the patient is there. If the patient comes in with no specific complaint, but you diagnose a medical problem, report the routine visit as the primary diagnosis and the medical condition as the secondary diagnosis. Bill that visit to the patient's vision carrier. Your diagnosis code must relate to the chief complaint -- so when the patient has no complaints, the visit is routine no matter what you find.

Check your codes: Many vision plans specify that you use HCPCS codes S0620 (Routine ophthalmological examination including refraction; new patient) and S0621 (... established patient) for a routine exam. Other plans may want the general ophthalmological services CPT codes 92002-92014. For example, Medicare does not accept the S codes, but many BlueCross BlueShield plans use them. So check with your individual carriers to be sure which code set you should use.

Have Patient Return for Further Tests

Experts say: When you do find a medical problem during a routine exam, you might consider having the patient return on another day for any further tests, rather than convert the exam from routine to medical. A patient who thought he had a routine screening with a $20 copay may be confused and upset when he sees a bill for a medical eye exam -- even if his out-of-pocket expenses are the same.

"It's the doctor's call on that situation, but think about how your patient may perceive it," advises David Gibson, OD, FAAO, an optometrist practicing in Lubbock, Texas. "Remember, the average patient does not understand the difference between a routine eye exam and a medical eye exam. Some patients are very protective of their 'free' routine eye exam and may be upset if they aren't allowed to use it."

Strategy: You can manage your patient for your longterm benefit, notes Gibson. "It has been my experience that allowing the patient to use their routine exam benefits at the initial visit creates a lot of good will and may be totally appropriate anyway as most glaucoma suspects don't start out with a complaint about their elevated pressures or unusual optic disc appearance."

Example: A patient with no complaint comes in for the routine eye exam that his vision insurance provides. You discover glaucoma. Bill the patient's vision insurance with S0620 or S0621, and link it to V72.0 (Examination of eyes and vision). As a secondary diagnosis, report the glaucoma (365.xx).

If there is a follow-up exam later, the medical condition will be the primary diagnosis and the bill goes to the patient's medical insurance.

When the patient returns for further diagnostic tests -- such as 9208x (Visual field examination, unilateral or bilateral, with interpretation and report ...) and 92020 (Gonioscopy [separate procedure]) -- link the codes to the glaucoma diagnosis, and send the claim to the medical insurer.

Bonus: There are times when you should bill both the patient's medical plan and vision plan. Caution: Report to both plans only when the carrier has instructed in writing you to do so. Also, when determining the service level for the problem visit, do not include physician work for glasses/contact lenses.

You shouldn't have a problem reporting noncovered services to a patient's secondary plan (for example, refractions, contact lens fittings, etc.), but you shouldn't submit an E/M code (99201-99215) and/or an eye code (92002-92014) to both of the patient's insurance plans unless instructed in writing to do so by both plans.

"In some cases of medical and routine plans together, you can bill the medical part to the health insurance company and a refraction only to the routine plan," says Gibson. "Some routine plans also pay the copay of the medical exam also as long as the total payment doesn't exceed the routine care benefit." Ask the routine plan representative how the policy indicates you should manage this and if the patient has a refraction only benefit.

Catch: You are not likely to bill a full exam to both companies, Gibson notes; doing so could be interpreted as double billing. "In some cases, the medical insurance is not aware of the routine plan as the employer has arranged for it separately," he says. "Again, check with the routinevision plan provider for guidelines."