Wiki medical vs. routine eye visit

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cmmfeyen

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I come from a background of medical coding, so this whole medical vs routine thing is very confusing to me and I’m hoping someone can help me understand it. In the medical world, we always put all the dx’s for that visit on the claim, why don’t we do that with eye care?

In medical, if a patient came in for a yearly physical, and they had another issue (pink eye) the provider would assign the Z00.00 (encounter for general adult medical exam w/o abnormal findings) and H10.33 (conjunctivitis, bilateral) the claim would go off and all would be good.

What I’m not understanding is why, if a patient comes in for a regular eye exam, and they have diabetes, we can’t send it to the insurance company with H53.031 (strabismic amblyopia, right eye) as the routine dx and E11.39 (Type 2 diabetes with other diabetic ophthalmic complication) as a secondary dx and H40.02 (Open angle with borderline findings, high risk) as tertiary dx’s? And if the pt wants it billed as medical – we remove the H53.031 and only submit the E11.39 and H40.02?

I’ve always been told to make sure all dx’s are on the primary cpt code (usually an exam) so this is weird to me to take some off and leave others on depending on whether it’s medical or routine. So other eye care facilities do this too??

Thank you so much!!!
 
Welcome to the world of eyes!
Most medical insurances do not cover refractive diagnoses and services because they have riders (vision plans) carved out that cover that. Routine services for things like all of the 'opia diagnoses, glasses, and contact lens services are vision benefits. The medical plan will deny your claim if you use the refractive diagnosis. You wouldn't bill dental services to the medical plan. Not to say that there are not plans that DO include one "routine" visit per year. Your CC/HPI really determines which plan you are billing and ideally if there are medical findings you are either having the patient come back for a medical work up and would use the medical diagnoses then or you switch to medical addressing the more urgent issues and have them return for the routine vision exam where you would use the refractive (for the most part) ones. There are other issues that factor in as well like the eye codes and whether your doc is an MD or an OD. If you are new to all of this and have the option, the American Academy of Ophthalmology (AAO) has great resources specific to these kinds of questions.
Hope this helped some!
 
Billing medical, whether the doctor is an OD or MD, shouldn't be different for either designation. Unfortunately, some insurance carriers discriminate against ODs and feel that all of their care should only be billed through a vision care plan (refractive care only), even if there is a medical diagnosis and medical care was rendered.
In general, as pointed out above, if you attach a refractive diagnosis code to a medical claim, it will be denied.

Tom Cheezum, OD, CPC, COPC
 
Question on this topic.. I have a patient that was seen for an office visit (99215) and several other test (92136, 92025, 92134). My question is, the provider has noted that for the 92025 the dx code that should be used is H52.212. This is going to a commercial UPMC healthplan, so am I correct to assume that this procedure will likely be denied due to the dx being a refractive code and not medical?
 
ENostrant11 said:
Question on this topic.. I have a patient that was seen for an office visit (99215) and several other test (92136, 92025, 92134). My question is, the provider has noted that for the 92025 the dx code that should be used is H52.212. This is going to a commercial UPMC healthplan, so am I correct to assume that this procedure will likely be denied due to the dx being a refractive code and not medical?
Click to expand...
Most likely, it will be denied. Also,despite the technology being around for a long time, some insurers still classify topography as being "experimental."
 
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