Wiki Pediatric "strabismus" and refractive diagnoses

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saddie2k

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We are newer to peds in our practice and our (also new to us) provider regularly lists refractive diagnoses in the plan. We keep these very separate with our other providers. Patients return for a refraction or for a medical work-up depending on the CC/HPI but we never mix the two in the impressions other than to indicate the need for a return visit. I know refractions can be medically billed but the plan for issuing the Rx is usually associated with the refractive dx vs the medical condition like esotropia in the impression. The routine refractive diagnoses should not be there, correct? At least not independently reported, right? Our billers are having a really hard time trying to determine what to do with them. We have tried to clarify with the provider but I feel like something is being lost in translation with the politics of who talks to who. Maybe we are not asking the right questions?
 
saddie2k said:
We are newer to peds in our practice and our (also new to us) provider regularly lists refractive diagnoses in the plan. We keep these very separate with our other providers. Patients return for a refraction or for a medical work-up depending on the CC/HPI but we never mix the two in the impressions other than to indicate the need for a return visit. I know refractions can be medically billed but the plan for issuing the Rx is usually associated with the refractive dx vs the medical condition like esotropia in the impression. The routine refractive diagnoses should not be there, correct? At least not independently reported, right? Our billers are having a really hard time trying to determine what to do with them. We have tried to clarify with the provider but I feel like something is being lost in translation with the politics of who talks to who. Maybe we are not asking the right questions?
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I code peds for a PCP's office but I'm having difficulty understanding your question. Can you rephrase this? Also what specialty are you in?
 
I believe I understand what you're asking so I'll try to answer. In general, you do not want to mix refractive and medical diagnoses because many insurers will deny the claim when they see the refractive codes associated with the exam code. So, for example, if the provider did a medical exam plus a refraction, the exam code would only have the medical diagnosis code for the esotropia associated with it and then you'd have the 92015 refraction code associated with the refractive codes. It's OK to have the refractive codes in the Impression part of the record but I would list them as separate parts fo the impression. Such as:
1) Esotrpoia
2) Hyperopic astigmat
 
Cheezum51 said:
I believe I understand what you're asking so I'll try to answer. In general, you do not want to mix refractive and medical diagnoses because many insurers will deny the claim when they see the refractive codes associated with the exam code. So, for example, if the provider did a medical exam plus a refraction, the exam code would only have the medical diagnosis code for the esotropia associated with it and then you'd have the 92015 refraction code associated with the refractive codes. It's OK to have the refractive codes in the Impression part of the record but I would list them as separate parts fo the impression. Such as:
1) Esotrpoia
2) Hyperopic astigmat
Click to expand...
Yes, thank you. Thats exactly what I was asking. Our other providers never include the refractive diagnoses in their impressions at all if the visit is to be billed to medical. So this new provider is throwing us off because we are confused on whether it was intended to be medical or vision. Then to further confuse, when the refraction was meant to be billed medically (MRx) for something like esotropia, the rx is being listed under the refractive diagnosis plan and not the esotropia. The diagnoses are always separately indicated like you listed above. It's just very confusing for us though the way this provider does it and was wondering if there is something we are missing in why the refractive diagnoses are always being listed but the patient is being seen for a medical visit. We have tried discussing with them to keep separate and bring back for one or the other if both are needed but it continues to happen.
 
saddie2k said:
Yes, thank you. Thats exactly what I was asking. Our other providers never include the refractive diagnoses in their impressions at all if the visit is to be billed to medical. So this new provider is throwing us off because we are confused on whether it was intended to be medical or vision. Then to further confuse, when the refraction was meant to be billed medically (MRx) for something like esotropia, the rx is being listed under the refractive diagnosis plan and not the esotropia. The diagnoses are always separately indicated like you listed above. It's just very confusing for us though the way this provider does it and was wondering if there is something we are missing in why the refractive diagnoses are always being listed but the patient is being seen for a medical visit. We have tried discussing with them to keep separate and bring back for one or the other if both are needed but it continues to happen.
Click to expand...
In general, hardly any medical insurer will pay for the 92015 refraction code, no matter what diagnosis codes you attach to it. We would always collect that fee from the patient at time of exam. You can do a medical exam on the same day you do a refraction, depending on the problem. In my experience, most patients who have a medical exam on one day are reluctant to return on a different day for just the refraction portion of the exam unless they also have to come back for more medical care.

Tom Cheezum, OD, CPC, COPC
 
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