Ophthalmology and Optometry Coding Alert

Medicare doesnt pay for refractions; some private policies do, but most dont. How can ophthalmologists get paid for doing refractions? We asked three coding experts for solutions to this ongoing problem. The code for refraction is 92015.

Part of the Exam

One answer is not to bill refractions at all, says Theresa Collins, insurance supervisor for Suncoast Eye Center, a seven-ophthalmologist, three-optometrist practice in Hudson, FL. With Medicare patients, we dont charge separately, says Collins. You know it wont be paid anyway. Collins uses the E/M services codes, not the eye codes.

Several people we spoke to indicated that they are billing the refractions separately. However, our experts warn that this could cause future problems in a Medicare audit. In Medicare, the refraction is never considered part of the exam. It doesnt matter whether the refraction was done for purposes of prescribing glasses or for medical diagnostic purposes; its not a covered Medicare benefit, period. And, if you include refraction services on your office visit claim, and are audited, the auditor will tell the carrier to deduct the amount for the refraction from the bill, which is usually 20 percent.

However, many HMOs and PPOs do consider a refraction included in the exam.

Note: If a Medicare patient comes in just for an eye exam, you cant bill Medicare for an office visit or anything else. We have to bill the patient then, Collins says.

Collecting From the Patient

The best solution is to collect payment for the refraction from the patient. With commercial HMOs, Collins does charge the patient for the refraction part of the office visit, if vision exams arent covered. The vision exam is separated from the other procedures, and the patient must pay. The key to making this work is collecting the money right away, she says. Yes, theres a PR problem with collecting this money, the insurance supervisor acknowledges. But the PR problem is much worse if you send a bill. The best way to handle this is to collect the fee at the desk the day the patient is seen.

We have the receptionist explain it to the patient on a face-to-face basis, explains Collins. But when it comes in the mail, the patient feels the insurance should pay for it. Then, it becomes a long drawn-out problem, with telephone calls back and forth and escalating annoyance on all sides.

If its done on a face-to-face basis, patients seem to understand, she says. If they have questions, we can explain that their insurance doesnt cover eye exams. Explaining this on the telephone after a bill has been sent is much more difficult. Then, its a billing situation, and the patient is defensive.

Mei Lam, billing manager for New York [...]