Wiki Annual eye exams

[mhoops]

I have never coded ophthalmology so please bear with me. I scheduled a routine eye exam for myself and my son which should be covered 100% under our health plan. Neither of us have had an eye exam in years. I was surprised to find that a copay was applied to our visits. They took the usual medical history, had us both read the eye chart, and then put drops in our eyes and put a machine up to our eye to measure the pressure (my son refused to allow them to take the pressure).

I called the insurance company and they said they billed a new patient office visit (99203) with a dx code of headache for my son's visit. I did mention during the history that he had headaches during school but we were there to make sure he was not having any vision problems which he does not.

I have contacted the office and they are adding the V72.0 code for the routine eye exam but am wondering if the CPT billed shouldn't be something from the ophthalmology section vs a regular E/M code. Again, I'm unfamiliar with what "normal" testing is for an eye exam so any help understanding this would be appreciated.

 

[LindaEV]

There are specific codes for eye exams, but MANY eye docs are now billing the E&M codes because of the better reimbursement. As soon as there is any sort of medical dx, they usually do this (e.g. headaches, diabetes...).

I have annual eye "wellness" exams for a $10 copay, but with my previous insurance I had to get a referral through my medical insurance and then pay a $65 specialist copay so they could bill my medical insurance. Thankfully I have better insurance now!

You could always ask for a copy of their note and make sure it meets the requirements for a 99203. Sounds like they didn't do much from your description.

 

[mzkandyd]

When billing for vision wellness, use V72.0 for your primary dx and the refractive diagnosis (if there is one) for your secondary dx.

With regards to CPT codes, some payers will want 92002-92004 or 92012-92014 AND 92015 (refraction).

I have some payers who would rather have S0620 or S0621 (these include refractions).