Wiki When to bill Vision insurance v. Medical insurance

[SarahSee1114]

I'm a coding student, but am curious about when ophthalmology and optometry bill a patient's vision insurance and other times bill medical insurance. For instance, if a patient has a medical history (glaucoma, diabetes, strabismus or even just dry eyes), but needs a routine exam -- Is this billed medical due to their history or vision due to their chief complaint?

 

[erinmiller]

coding ophthalmology x3 yrs

Based on all of these being medical (glaucoma, diabetes, strabismus) I would bill to the medical insurance. We bill strictly to medical due to having 4 ophthalmologists in our office, & depending on their medical insurance, a lot of them will cover a medical routine eye exam based on these dx. Hope this helps

EMiller CPC

 

[monopoly222]

Depends....on the insurance and what the insurance company guideline requires. We have local hospitals and other huge employers that have medical insurance that will pay for V72.0 routine eye exams per pt's policies....if a diagnostic code is used as primary instead of V72.0 then the medical insurance denies, applies to DNM, or pays at a lower rate.

Vision plans....depends on the vision plan.

You need to check with each insurance as to their policy for eye exams.

Shelley, CPC, CPB
10 years Optometry
25 years Coding Mult-Specialities
34 year in Medical Field

 

[kaylawardle]

As a general rule of thumb in my office, if the patient has a medical condition that the doctor assesses while doing the examination, we bill the medical insurance. Glaucoma, cataracts, AMD, etc. all affect the general exam, and it would be difficult to thoroughly assess the eye and just ignore these conditions.

We only bill the vision insurance if the diagnosis is refractive.

 

[yukiki12]

I just started working at an optometry clinic, and I am new to when to bill vision or medical claims. Where can I learn more about this at? Is this a seminar or something to go learn it? Please I need help.

 

[Cheezum51]

There are several good books available that are eye care specific. Not sure if I can recommend a specific book but one I read recently was written by Jeffrey Restuccio, CPC, COC who has been involved with eye care coding for over 20 years and lectures extensively. His book is available on line. When you see the title, you'll know the book I'm referring to.

I will tell you that, having worked with many eye care providers as a consultant, that you can't assume that your doctor knows the nuances involved with the question you asked. Many assume they know but really don't. I personally didn't understand fully the answer to your question until I became a certified coder.

Tom Cheezum, O.D., CPC, COPC