One of the most complex things we learn in our postgraduate training is how to report the services that we perform to third-party payers. What I have found to be the biggest challenge is that there are no consistent rules for coding among the different carriers.
The only guidance we have in the selection of the appropriate way to report the level of service necessary to address the patient’s problems is through well defined Current Procedural Terminology (CPT).
The CPT system was developed by the American Medical Association to answer these consistency concerns. Codes are analyzed for both validity and value. The CPT
Editorial Panel is comprised of representatives from every discipline of medicine, optometry, dentistry, podiatry and all other health care providers.
The panel’s work is to develop detailed definitions for every procedure code; in doing so, they analyze procedure codes and determine the examination elements to be assigned to that code.
Once a code passes their scrutiny and is adopted, it is then sent to the Relative Value Scale Update Committee (RUC). RUC analyzes the work, effort and time involved in performing the procedure and assigns a value to the code.
This two-step process allows for a very detailed analysis of each and every CPT code. The RUC’s final decision ultimately translates the relative value of the code into a dollar value by a third-party payer. This system is by no means perfect, but it does attempt to fairly quantify a value for the time that you must spend in caring for your patients.
CPT codes used to report eye care services are 920XX and 990XX, and offer a wide selection of choice for accurate reporting of services.
S Codes Are Ill Defined
In stark contrast are the S codes. The only associated definition is broadly written as “Routine ophthalmological examination including refraction.” S codes are traditionally used in cases in which there are no nationally accepted CPT codes for reporting the use of medications, medical supplies or services. Most doctors don’t realize that there is no accepted definition to the level of service necessary or elements of the examination when reporting an examination using an S code.
In fact, there are just a few insurers who mandate reporting services using the S codes. CPT 920XX and 990XX are preferred because of their clear definitions and valuation. They are very easy to apply—you must simply meet the definition and have performed the required elements to bill for services using these codes. Also, you must always select a code based on the service provided during the examination (elements), and your medical record (not the diagnosis) must support this.
The CPT office visit codes (990XX and 920XX) have very detailed definitions that list the tests that are expected and/or structures to be examined when a specific level of service is reported. This allows for more accurate reporting based on the content of the medical record.
The CPT definitions also are necessary for reporting quality measures when billing eye care services to insurers, as well as for those reviewing or auditing clinical records.
S codes have neither of these attributes. This fact alone has far-reaching implications for optometrists as members of the primary health care team, and we must ensure that the services that we perform are reported in a measurable, credible and auditable way.
Further, with health care reform placing additional emphasis on quality outcomes, we must remain vigilant to ensure that optometric services are fully included in these assessments.
Invalid and Inappropriate
Our colleagues in medicine rarely use S codes to report the services they perform. As a result, S codes have been referred to as “optometry codes.” If we report our services in a different way than other providers providing the same services, we run a significant risk for our profession to be “carved out” of the mainstream health care system.
The S code also bundles refraction with the comprehensive ophthalmological examination. This doesn’t comply with the mandates of the HIPAA law, which says that it’s illegal to bundle separately reported services into a single code. Because of this, the validity of using this code to report these bundled services must be called into question.
Some providers inappropriately use S codes as a way to bill lesser amounts for comprehensive eye care services when a patient presents with no obvious medical complaint or ultimately has a refractive diagnosis. Clearly, there is significant risk in reporting services in this way.
Ultimately, it is inappropriate—and in some cases, a violation of the insurance contract—to bill insurers different amounts for the same service performed.
By reporting the services you perform using CPT 920XX or 990XX codes exclusively, you are able to justify the level of work effort necessary to perform the office visit. The patient record reflects the elements of the examination and provides ample facts supporting your charges.
Simply put, the value of the comprehensive examination does not change when utilizing an S code for private pay patients!
Optometrists play an ever-increasing role as members of the primary health care team, and using S codes poses many risks for access to the full range of optometric services. There are many reasons for optometrists to steer clear of these poorly defined codes.
The S code is relic of the past. Health reform is upon us, so it is important to look to the health care environment of today and tomorrow—not only for the best way to care for our patients, but also for the best way to report that care.
Dwight D. Eisenhower once said, “Neither a wise man nor a brave man lies down on the tracks of history to wait for the train of the future to run over him.”
Let’s not get run over by that train!
Dr. Montaquila is chair of the American Optometric Association Third Party Center Executive Committee, and in private practice in Warwick, R.I. Send comments to