Wiki Medicaid refractions

[ded1982]

I am told that there is a way to get Medicaid to pay for the refraction portion of the exam IF Medicare pays on the exam portion. However, I cannot figure out what the trick is to getting these paid. Every time I call Medicaid regarding a claim that has cross overed from Medicare they tell me that refractions are only covered if Medicare pays on the exam but they are unable to tell me what I need to do to get it paid. It keeps being denied, saying that the refraction can not be billed on the same day as an exam. Has anybody figured out how to bill these refractions to Medicaid to receive payment on them? As of right now we end up writing off every refraction for Medicaid patients. Thanks in advance!

 

[debra carter]

Medicaid Refraction Codes

check out this reference from the Medicaid billing guidelines:
http://www.ncdhhs.gov/dma/mp/6A.pdf

• New patient routine eye exams (S0620) are limited to once every three years for the same
recipient and same provider.
• Office visits and consultations are included in the routine eye examination and must not
be billed separately. Exceptions are allowed with documentation of medical necessity.
• Medical ophthalmolgical exams and office visits must not be billed by the same provider
on the same day as a routine eye exam (S0620 or S0621) or a refraction only
(92015).
• When billing a refraction code (S0620, S0621 or 92015), providers use a refractive
diagnosis as the primary diagnosis code. If a medical diagnosis is used, the claim will be
denied. One of the following diagnosis codes must be the primary diagnosis for payment
of the refraction:
Code Diagnosis
367.0 Hyperopia
367.1 Myopia
367.2 Astigmatism
367.3 Anisometropia/Aniseikonia
367.4 Presbyopia
367.5 Disorders of accommodation
367.8 Other disorders of refraction and accommodation
367.9 Unspecified disorders of refraction and accommodation
V72.0 Routine eye examination, emmetropia (no correction required)