Optometry Coding & Billing Alert

Published on Wed Jan 26, 2005 PDF

Question: We offer our patients routine healthy baseline photos of the retina and disc. We charge a fee for this, and the patient is aware that insurance will not cover it. We still charge the patient for the photo even if during the exam the medical diagnosis supports taking the photo. Is this OK, or should we bill insurance instead?

Vermont Subscriber

Answer: Billing for the baseline photos follows a logical thought pattern. You can bill the patient's insurance for the picture if you are documenting a pathological condition or the change in a pathological condition. However, don't confuse the ability to bill for the picture with the ability to bill for the exam at the same time.

If the patient came in for a routine exam and had no complaints, that exam is routine, no matter what you find. If you find pathology during that routine exam, it is still a routine exam, but any additional testing would not have to be considered routine. In those cases, it's sometimes better to have the patient back on another day to take the picture and do any further testing if at all possible.

Smart: Most routine exams with routine pictures do not show any pathology and therefore remain the financial responsibility of the patient or his vision plan. Consider having your patients read and sign a form explaining the purpose of routine retinal photography, telling the costs and explaining that insurance covers it only if a medical diagnosis is found. The same form can also cover the need for polycarbonate lenses and ask for permission to dilate.
 
At that point, you could bill Medicare or the insurance for the photos, but just be sure to append modifier -GA (Waiver of liability statement on file). If you get a denial, bill the patient.