H52.4 as a primary dx for routine vision exams?

briansmith99

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Hi There,

Our office got an unusual response from a Medicare Advantage insurer when we billed 92014 for an established patient and a 92015 (refraction) with diagnosis codes linked in the following order.

92014 - H52.13, H52.223 & H52.4
92015 - H52.13, H52.223 & H52.4

The response we got was indicating that the order of linkage was incorrect and that for 92015 to be considered payable that H52.4 had to be the primary dx code used.

Is that correct?

Thanks!

Brian
 

Cheezum51

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The 92014 shouldn't be payable with any of those codes because they're all refractive diagnosis codes.

For the 92015, it really shouldn't matter what order you code the refractive codes, in my opinion. They're not going to pay that anyhow. Medicare doesn't pay for refractions.

Tom Cheezum, O.D., CPC
 

Cheezum51

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I just caught that the title of your question refers to "routine exams."

If these exams have no medical diagnosis and the problems are purely refractive in nature, then Medicare will not pay for the 92014 either because there's no "Medical necessity" for the exam.

In that case, the patient would be responsible for paying for both the 92014 and the 92015.

Tom Cheezum, O.D., CPC

PS - just a word of advice. If the wording "routine exam" is used in the chief complaint portion of the exam record, that can automatically disqualify it for medical reimbursement. It would also be fairly unusual for a Medicare aged patient not to have some medical eye problems such as cataracts or vitreous detachment/floater.
 

briansmith99

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Dr Cheezum,

Thanks very much for the reply. Its an odd question, of course, because you are right. Medicare will not pay for refractive services. Commercial plans though, offering Medicare Advantage plans, are able to offer a variety of services to medicare eligible patients who choose to purchase those advantage plans instead of original medicare. Since this company was one of those who offer a covered 'routine vision' exam for their members we were a bit surprised to find this claim out of many which was denied and with such an unusual explanation.

Probably the situation is too odd to have precedence but I was curious to know from a coder's stand point if ICD 10 was designed to indicate a need to have H52.4 listed as a primary DX over other refractive diagnoses, ever.

Its hard to respond sometimes to insurance companies when they come up with obscure or perhaps random or even incorrect reasons for their denials. In this case, I'm happy to hear you say there is no order of supremacy in the refractive diagnoses H52.13, H52.223 and H52.4 as that fits my understanding of coding with ICD 10.

With that in hand I'll go back to the insurance company and perhaps will get a different reason for the denial, perhaps something more understandable.

Thanks again!
 
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