Optometry Coding & Billing Alert

Published on Wed Jan 26, 2005 PDF

Question: A patient comes in with insurance that covers 80 percent of the allowable amount on glasses. We bill the frame as V2020 for the basic part and V2025 as the additional amount. The insurance is paying one or the other and requiring us to write off the total remaining balance.
 
Do you have any suggestions on how to collect the extra amount on the frame when a patient chooses to purchase a better frame than the basic?

Utah Subscriber

Answer: The answer depends on the carrier. For Medicare, HCPCS codes V2020 (Frames, purchases) and V2025 (Deluxe frame) are appropriate. Medicare allows a certain amount for a frame after cataract surgery, and the excess of the frame allowance is billed as V2025. When Medicare processes the claim, the V2025 is accepted by Medicare but is clearly shown to be the patient's responsibility.

It's a good idea to collect for the V2025 amount and 20 percent of the V2020 fee (if the patient doesn't have a Medigap plan) while the patient is in the office.

You would not, however, use both of those codes for private vision plans. Most non-Medicare vision plans will reimburse only a fixed amount for frames.

Example: A plan might pay $80 for any frame up to a retail value of $115, with the patient paying 80 percent of anything over $115. If a patient selects a $150 frame, he pays $28 (80 percent of the $35 overage) and the insurance plan pays $80.
 
Experts warn: If a vision plan doesn't set a maximum frame price but will still only reimburse a fixed amount, you could end up providing a frame that cost you more than the insurance company is paying. Agreeing to accept such a plan would be a mistake.