Ophthalmology and Optometry Coding Alert

Some patients who come into the office for an eye exam deny they have vision problems. Ophthalmologists should determine the medical complaint by taking the patient history and thoroughly documenting it to get paid for these visits and to avoid fraud.

If you bill Medicare for an eye exam 92002, 92004, 92012 or 92014 you need to have documentation that supports the service as reasonable and necessary (just as you do for any claim). If the patient comes to your office and says, I need glasses, you must proceed very carefully in the history to find out if there are any medical problems, and you must document carefully as well. Failing to take a good history could mean that you cant bill Medicare for the exam because it will appear to be a routine service, and you will have to bill the patient. And failing to document well means that if you are audited you may have to refund the fee, pay a fine or submit to constant audits.

But the problem is that many patients are in denial about their vision problems. If they insist that they need a routine check-up for glasses and that they dont have any problems including vision problems you cannot bill Medicare for the visit, regardless of what you find in the exam. This is because Medicare has a long-standing national policy that the reason for the encounter determines reasonable and necessary services. This may happen when a Medicare patient comes in and doesnt want to admit that he or she might have a cataract, and so denies any vision problems at all. Following is an example:

Scenario: A patient comes in with 20/100 vision that cant be improved by any amount of refractive correction. Yet the patient has no complaint at all, merely stating, I just need a check-up to see if I need new glasses. Subsequently, a cataract is found. But with no complaint in the chart, there is no way that visit can be billed to Medicare. If the patient didnt complain, the patient pays, says Patricia Kennedy, COMT, associate consultant at Corcoran Consulting Group, a San Bernardino, Calif.-based ophthalmology coding and reimbursement consulting firm. Thats why, when training technicians, I tell them to leave the history blank until they start the refraction. Then, you can say, You did have 20/30 vision, now you have 20/100, are you having any problems? And the patient may, at that point, say, Well, I did notice the other day that I couldnt see the golf ball after I hit it. And there, explains Kennedy, is the medical necessity. Medicare will look for documentation of impaired daily living activities in the [...]