Wiki S Code vs 92XXX code for Optometrist?

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akwilliams2

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Hello All! I currently am billing for an Optometrist who works out of a Walmart practice in Virginia. (I just took this on about 3 weeks ago)

For patients whose insurance he does not participate with he charges $64 and has been billing S0620 to the non-participating insurances (out of network VSP mainly) ---- for major carriers that he participates w/he bills 92014 for $150 and 92015 for $25-----can he continue doing this? Or should he be billing everyone the $175 charge and taking the write off?

Any guidance would be great!

Thanks
 
Some payers want S0620, S0621 codes and others want the actual Eye Codes (92xxx). I would refer back to your billing guidelines with your payers.
 
Is he using the "S" codes for "routine" exams that only have a refractive diagnosis and the 92xxx codes for those patients who have a medical diagnosis?
 
He was using S-codes for self pay patients and vision insurances and 92xxx codes for medical insurances----

His exam is $150, refraction $25---self pay patients get a HUGE discount down to $64-----I just took over after a fired office manager and am trying to get them on track....he believes that the S-Code allows for a self pay patient to receive a discount---I thought all insurances needed to be billed the same so I have been billing all insurances (vision and medical) the larger amount and showing the S-code as $175 discounted down to $64?
 
I'm not sure that VSP recognizes the S codes for billing purposes. We always used either the 99xxx or 92xxx codes for our exams.

One question you should ask is whether all of his patients are being dilated for their exams. If not, that violates the VSP exam guidelines and he could be in trouble with an audit.

The 92xxx and 99xxx codes for comprehensive exams do require dilation whereas the S codes say that dilation is optional. We had very few vision or insurance plans that accepted the S codes so I would not use them for any claims you bill.

Also, if a refraction was done for the patients, be sure to bill the 92015 in addition to the exam codes.

If you want to bill the vision plans for the $175, knowing you'll have to do a write off, that won't be a problem. It's just more work for the book keeper. We would usually bill the vision plans (VSP, Eyemed, Davis Vision) what we knew they were going to pay so our accounts receivable weren't artificially inflated by the large amounts we would have to write off for them if we billed full fee.

Tom Cheezum, O.D., CPC
 
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