Exam Level Matters in Ophthalmology

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  • August 1, 2009
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Knowing when to bill a medical exam versus a routine vision exam ensures proper reimbursement.

By Jennifer Worthy, CPC, OCS
To minimize a patient’s financial responsibility when paying for vision care, you should understand when it’s appropriate to bill a medical exam versus a routine vision exam. Knowing the difference, and clearly communicating it to patients prior to rendering services, can save you a lot of time educating the patient—and sometimes the payer—as to why the claim processed the way it did.

Understand Medical Plans vs. Vision Plans

Always bill an evaluation of an acute complaint, a full exam for an existing medical condition, or a consultation for a medical complaint to the patient’s medical plan. Exams to check normal or healthy vision, screening for eye diseases, or an exam to update eye glasses or contact lenses should be billed to the patient’s vision plan.
ICD-9-CM code V72.0 Examination of eyes and vision and screening codes, such as V80.1 Special screening neurological, eye, and ear diseases; glaucoma, are examples of diagnosis codes you should submit to a vision plan for a routine eye exam. Most payers, including Medicare, do not recognize the majority of diagnosis codes in the 367 Disorders of refraction and accommodation code set as medical reasons for an eye exam. These codes indicate refractive errors such as myopia, astigmatism, and presbyopia.
Often, a medical condition found during a routine eye exam supersedes a routine diagnosis. This holds true for optometrists who perform routine eye exams and encounter a medical problem during that exam. Clearly explain this to patients at the time services are rendered.

Shed Light on Patient Coverage

Make patients aware of coverage limitations when they present for a routine exam that subsequently becomes medical in nature. A patient can become confused when he or she finds an exam isn’t covered by insurance. If a patient is insistent that you resubmit a claim, tactfully decline and review the medical record with the patient—pointing out the chief complaint and how the physician addressed those complaints. If applicable, remind the patient of any testing done and the findings.
Resubmitting a claim to assist a patient in avoiding financial responsibility is not appropriate. Providing a clear explanation to the patient—even if he or she still is dissatisfied with your decision not to resubmit a claim—will help the patient understand your position.
Medicare does not cover routine annual exams. Beneficiaries may choose to have an annual exam but if there isn’t a medically necessary reason for the visit a beneficiary is responsible for the cost. Asking the patient to sign an advanced beneficiary notice (ABN) for such visits isn’t necessary because routine care is considered a non-covered service and clearly indicated by Medicare law. It is the beneficiaries’ responsibility to understand the limitations of Medicare coverage.
As private fee-for-service plans enter the market, they are expanding their covered services to beneficiaries to remain competitive. This can include covering routine eye exams. Just as you would treat a patient with commercial coverage, you should make sure beneficiaries are familiar with their plan’s coverage limitations.

Know Carrier Limitations

Prior to 1996, commercial payers could create and use their own code sets for many services, including routine eye care exams. After Health Insurance Portability and Accountability Act (HIPAA) implementation, some payers replaced their routine eye codes with HCPCS Level II codes.
Codes S0620 Routine ophthalmological examination including refraction; new patient and S0621 Routine ophthalmological examination including refraction; established patient specifically describe routine eye exams, including refraction.
You would use these codes for healthy patients who present for routine eye exams for new eyeglasses or contact lenses. Medicare doesn’t accept these codes; however, commercial plans, such as Aetna, recognize these codes and would expect them to be present on the claim for a true routine eye exam.
If your ophthalmology practice accepts both medical and vision plans, you may submit claims to both payers in certain situations. A patient may, for example, present for a routine eye exam with refraction at which time a medical condition is identified. In this case, one of two things can happen.
The patient may choose to continue with the routine eye exam, as covered by a vision plan, and return at a later date for treatment of the incidental finding. If so, you would bill the subsequent exam to monitor or treat the medical condition to the patient’s medical plan.
The patient may choose to proceed with the medical exam. If so, you should make the patient aware that his or her plan may have exclusions and/or limitations that require an applicable specialist co-payment, primary care physician referral (when required), deductable, and/or co-insurance.
Although some major medical plans allow a benefit for routine eye exams, the patient needs to understand the terms of his or her coverage, and at what point a routine exam turns medical, to avoid confusion.
In any case, the exception to this would be an emergency or urgent condition where delaying treatment is not an option to the physician or optometrist.

Restore 20/20 Vision

Whether you are in an optometry practice or ophthalmology practice, understanding the reason for a patient’s visit will limit confusion. Remember that patients often don’t understand the difference between optometric care and ophthalmology care. Patient education and consistency among staff to understand limitations of coverage can also help alleviate any confusion for the patient. Developing a system within your practice to alert clerical and clinical staff about the limitations of a patient’s coverage is an effective way to avoid any miscommunication later on with a patient.
Jennifer Worthy, CPC, OCS, is a patient account specialist for Eyecare Medical Group in Portland, Maine. She enjoys the challenge of coding in an environment that offers a range of billable services. She has been in the ophthalmology field for six years.

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