Wiki Refraction time in low vision eye exams

[Cheezum51]

Refraction, 92015, has always been a code which isn't covered by Medicare and most other medical carriers. Since it's a procedure which has it's own CPT code and is reimbursed by direct patient payment to the provider, I don't believe it should be counted as part of the time when a provider uses Time to select the E/M.

To me, as an eye doctor, the refraction is the procedure to determine what eyeglass prescription is needed to provide the best visual acuity for the patient with glasses. Once you gather that information, you then use it to determine which low vision devices help the patient meet their ADL vision goals.

Now to my question. Historically, most low vision providers tend to charge a high fee for the refraction portion of their total exam fee to also cover the effort needed to determine which low vision aids (magnifiers, telescopes, CCTV reading devices) to prescribe for these patients. Personally, I feel that the time needed to evaluate those devices is along the lines of an occupational therapy evaluation and should be included in determining the total doctor time used to select the E/M code for the overall exam.

Any input or thoughts would be appreciated. I've not been able to find any guidance on this from Medicare or other insurers.

 

[thomas7331]

I don't know the coding of eye specialties well, but I would be inclined to agree with you on this if the sole purpose of the refraction was, as you've described, to determine the prescription for eyeglasses as a routine corrective vision service. But in the case of an E&M service, which is by definition directed at the diagnosis and/or treatment of a covered illness or injury, wouldn't a refraction be a medically necessary component of the eye exam (for example, in a visit to evaluate a complaint of a sudden change of vision in a patient)? If that's the case, and given that the refraction is not billed separately, it seems to me that the time spent by a physician doing this would be appropriately included in the E&M code choice. Just my initial thoughts but perhaps someone else might add to this.

 

[Cheezum51]

I don't know the coding of eye specialties well, but I would be inclined to agree with you on this if the sole purpose of the refraction was, as you've described, to determine the prescription for eyeglasses as a routine corrective vision service. But in the case of an E&M service, which is by definition directed at the diagnosis and/or treatment of a covered illness or injury, wouldn't a refraction be a medically necessary component of the eye exam (for example, in a visit to evaluate a complaint of a sudden change of vision in a patient)? If that's the case, and given that the refraction is not billed separately, it seems to me that the time spent by a physician doing this would be appropriately included in the E&M code choice. Just my initial thoughts but perhaps someone else might add to this.

Thanks for your thoughts. The refraction isn't billed to Medicare or other insurers because it isn't a covered service. It is billed to the patients and they pay for the 92015 out of pocket. VERY RARELY, you'll have a commercial carrier which will pay for the 92015. Maybe 1 or 2 per year.