Here's one example:
http://www.ophthalmologymanagement.com/articleviewer.aspx?articleid=86253
"Q: If a patient has both medical and vision insurance, which is primary?"
A: It depends on the reason for the visit, from the patient's perspective. Exams for medical care, evaluation of a complaint, or to follow an existing medical condition should be billed to the medical plan. Exams to check vision, screen for disease, or update eyeglasses or contact lenses should be billed to the patient or the patient's vision plan.
"Q: If a patient comes in for a routine vision exam and we find pathology, can we bill the medical plan?"
A: Unless you find an urgent or emergent medical condition, the chief complaint should comport with the primary diagnosis and determine coverage. For example, the chart may read: "Here for routine eye exam and new glasses" with a corresponding diagnosis of refractive error. The incidental finding of pathology should be addressed on a return visit. (Subsequent exams to monitor or treat the pathology can be billed to the medical plan.)
Of course if the patient agrees to same-day additional testing due to their condition, those tests would go medical. But I still have to maintain that, unless the patient agrees otherwise, one should bill the services the patient came in for in the way they were quoted at the time of the appointment.
I would add that communication with the patient is key here. If the doctor finds pathology, communicates that to the patient, and the patient agrees to convert the exam into a medical exam (and pay the most likely higher cost of the specialist copay), then there's no reason to force the pt to come back for another exam. But from everything I've read, you're not allowed to do the "bait and switch" with the patient (book them for a routine eye exam and convert it to medical without their approval). In my experience that makes patients pretty mad because it almost always means higher costs.
Many providers don't like this guideline because they feel that patients with pathology are going to take more time than patients with no pathology and therefore they should be allowed to bill the medical plan instead of the vision plan in order to get higher reimbursement, but I just don't think that's correct coding. (I think the problem here is the dismally low reimbursement most vision plans offer!) But the bottom line is, the vision plan is reimbursing the doctor for a comprehensive eye exam with refraction, not just the refraction. The vision plans are expecting some of their members to have comorbidities (eg, VSP requires you to list them when you file the claim). So, I would say that presence and/or management of a comorbidity does not automatically preclude one from filing the exam to the vision plan, low reimbursement or not.
Medical decision making is part of E/M coding, but is not listed as a factor in the ophthalmology codes, so in my opinion even very high medical decision making can be billed with 92xxx. And per ICD-9 Guidelines "List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." I have always been taught that this means the reason for encounter (i.e. chief complaint) drives selection of primary diagnosis, which then will drive selection of insurance.
Just my two cents.
