Optometry Coding & Billing Alert

Question: If a patient with both medical and vision insurance comes in for a routine exam and during the examination a medical problem is found, can I bill the medical plan instead of the vision plan?


Massachusetts Subscriber


Answer: The answer depends on the patient's chief complaint. If a patient presents with no complaints, but you find something that makes it necessary to perform tests in addition to the routine screening, you may be able to bill both the medical insurance and the vision insurance.

Bill the eye exam with the appropriate eye code to the patient's vision insurance. Bill any additional tests you perform (e.g., visual fields or extended ophthalmoscopy) as a result of the medical problem you found to the medical insurance. You can bill for medical tests performed on the same day as the initial visit, but it may be best to have the patient return to the office a different day to address the medical issues, to make it very clear that it was a medical visit. Link the additional tests to the appropriate ICD-9 code for the medical problem.

If the patient presents with a specific complaint that can be attributed to a non-refractive diagnosis, then it's a medical visit and should be billed to the medical insurance.