Wiki Billing Refraction with Exam

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edmedbilling

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Hello,
In our office we split vision and exam codes 99214 or 92014 (etc.) and bill the refraction 92015 for (H52.4 Presbyopia) separate. I was told this was done because it had caused problems with medicare and commercial claims.

Anyone hear of this practice? Or why it would affect medicare or other payer claims?

Thank you!

Edward
 
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The refraction, 92015, has been a service which Medicare has never paid for. Very rarely, a commercial carrier will pay that code. The refraction is also not an exam element of any of the 99 or 92 codes used for eye care. Therefore, you have to bill that as an additional service code when you bill your 92 or 99 code.

First of all, unless you know for sure that a carrier will pay for the refraction, you should always collect the fee for that service at the time of the exam. We always billed it for two reasons:
1) For the patient to see on their EOB that the insurer didn't pay for the 92015 and that it was their responsibility.
2) So if, by some chance, it is paid by the carrier, you can then reimburse the patient for the amount the insurer paid.

Tom Cheezum, OD, CPC, COPC
 
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Cheezum51 said:
The refraction, 92015, has been a service which Medicare has never paid for. Very rarely, a commercial carrier will pay that code. The refraction is also not an exam element of any of the 99 or 92 codes used for eye care. Therefore, you have to bill that as an additional service code when you bill your 92 or 99 code.
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Hi Tom,
Thank you for your reply. We bill it for the same reasons, so the patient can see it and so their secondary can pay for it. Many times the secondary will pick it up for our patients.

So do I need to split the claim into two? An exam claim and a claim just for the refraction or can they all go on the same bill?

Edward
 
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Edward,

Just submit the exam and refraction codes on the same bill. Make sure that you only use the refractive ICD-10 codes for the 92015 and not the medical diagnosis codes that you use for the 99 or 92 exam code.

Tom Cheezum, OD, CPC, COPC
 
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Hi there I am new to Ophthalmology coding and have come across an insurance who will not pay on the refraction stating that it is a bundled service with the exam code..how do I go about this.. Could it be that they are following what medicare does or can I appeal this stating it is not a bundled service...
 
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First of all, are you sure it's a medical insurer or is it a Vision Care Plan (VSP, Davis Vision, EyeMed, Superior Vision)? If it's a VCP, they are just discount vision plans which include payment for a "wellness" eye exam, including refraction, and do not pay for medical eye care. Medicare DOES NOT bundle the refraction with the exam codes, 92 or 99, they pay. 92015 has NEVER been bundled as part of a 92 or 99 exam code by any medical insurer I'm aware of.

Tom Cheezum, OD, CPC, COPC
 
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I have a question regardng the new MDM guidelines for 2021. If a provider does a refraction but does not bill for it ( the patient also refuses new glasses and we have no actual rx in the documentation only that a refraction exam was done) how would we count this in determining the level of MDM under the new guidelines, or would we? This is for an optometrist not an opthalmologist and the claim was for diabetic patient who came in for a "diabetic exam" can we count the rx for glasses even though refused by pateint as "perscription drug management" under the new 2021 guidelines.
 
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Scenario & question about balance billing & contracts with regard to refractions:
  1. The patient signs a financial agreement to pay $50 at the time of service for refraction
  2. The patient pays the $50 and asks for a detailed bill so they can try to submit it to insurance for reimbursement.
  3. The insurance receives the patient's request and sends electronic payment to the provider for LESS than $50
  4. Can I reimburse the patient what the insurance pays the provider or is this a breach of contract?
  5. I have sent the payment back to the insurance and ask them to reimburse the patient - but the insurance sends the check right back!
Thank you for your help!
Jenna, CPPM
 
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