Ophthalmology and Optometry Coding Alert

To get paid for refractions ophthalmology practices should have the patient sign a waiver, understand commercial policy and understand patients rights.

Its no secret that Medicare wont pay for refractions, code 92015 (determination of refractive state). As for commercial plans, many times coverage does seem secretive. Patients often dont even know what their own coverage is. As one biller puts it, Refractions are a jungle.

But this doesnt mean you cant get paid for refractions. Although, the patient has to pay most of the time, there are rules for how this is to be done. Here are some tips:

1. Have the patient sign a waiver form. Although a waiver of liability form is not required by Medicare for services that are always non-covered, many practices have the patient sign one anyway as a way of informing them in advance that the refraction will not be covered by Medicare, says Lise Roberts, vice president of Health Care Compliance Strategies of Syosset, N.Y . This is an often misunderstood area, explains Roberts. Patients do not have to sign waivers of liability when a service is always non-covered, she says. Waivers are only required when a service is sometimes covered by Medicare, but in this instance, billing wont be covered.

Refractions are never under any circumstances paid by Medicare. They are not a benefit of the Medicare program. This is clearly stated in the Medicare Beneficiaries Handbook which the beneficiary receives when they first enroll in Medicare Part B, notes Roberts. With Medicare, you can only bill patients if its a non-covered service.

Because the service of refraction is not a benefit of the Medicare program and is always not covered by Medicare, you are allowed to bill patients directly for the refractions, Roberts says.

Most Medicare patients are getting this message now, says Jeri Groesch, billing clerk for South Hills Eye Associates of Pittsburgh, Pa. We know ahead of time if the patient is on Medicare, and we have them sign the waiver.

2. Determine commercial policy. Commercial, PPO and HMO plans are different. We dont know how the insurance works until the patient is here, says Groesch. The front desk clerk must ask. Some patients know if they have vision coverage, but some just think they do. And some dont know at all. If the patient doesnt know whether they have vision coverage, as a courtesy, we will file the claim and wait for the EOB, says Groesch. When it comes back and the refraction isnt covered, we collect the fee from the patient.

This can be tricky, though, because sometimes the payer denies payment because they consider the refraction included in the eye exam code [...]