Do We Bill Eye Exams to Medical or Vision Coverage?
Question: An established patient presented for their annual eye exam. The physician didn’t note any concerns, but they did document bilateral myopia and history of retinopathy of prematurity. The patient’s payer is commercial insurance, but they also have vision coverage through a different payer. Should we bill the encounter to the medical insurance or the vision coverage since we’re billing for vision services? New York Subscriber Answer: Based on the information you’ve provided, you’ll bill the encounter to the patient’s vision coverage. The encounter is a routine annual eye examination for refractive care. The physician documented bilateral myopia and a history of retinopathy of prematurity (ROP). Myopia is a refractive condition that is usually covered under vision benefits. Meanwhile, the history of ROP doesn’t support medical necessity for medical insurance coverage, unless the provider evaluated, monitored, or managed the condition during the visit. For this encounter, you’ll assign one of the following eye examination codes, depending on whether the physician documented an intermediate or comprehensive examination: You’ll then use Z01.00 (Encounter for examination of eyes and vision without abnormal findings) and H52.13 (Myopia, bilateral) to report the reason for the examination and the patient’s existing condition. Don’t worry about the history of ROP code unless the documentation indicates the ROP history is clinically relevant and the physician factored it in when determining the patient’s care. Remember: Of course, individual payers have different policies and preferences for how you should report services. Double-checking with the patient’s medical and vision payers is a good idea to avoid a denial down the road. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
