Your practice is likely to recoup more from billing your patients medical insurance than from billing their vision insurance. This is because more people have medical insurance than vision insurance. Plus, medical reimbursements are almost always higher than vision plan reimbursements. Below, learn the common mistakes many medical billing freshmen make so you can avoid them, and maximize your reimbursements.
Medical billing and coding can be frustrating, but by understanding common mistakes, you can avoid them and maximize your reimbursements.
Medical vs. Vision Plan Billing
Medical carriers recognize and pay the same codes used by vision carriers. These include:
92004: Comprehensive Ophthalmologic Evaluation, New Patient.
92014: Comprehensive Ophthalmologic Evaluation, Established Patient.
92002: Intermediate Ophthalmologic Evaluation, New Patient.
92012: Intermediate Ophthalmologic Evaluation, Established Patient.
Many optometrists who bill medical carriers for eye exams do not get reimbursed. This is because they make errors due to a lack of understanding about medical billing rules, which are very different than vision plan billing rules. Understanding these rules is crucial for getting paid by the medical carrier and surviving an audit.
Medical Billing Mistakes
O.D.s typically make two mistakes when they begin billing eye exams to medical carriers. These include:
1. Submitting a 92000 eye exam procedure code with a refractive diagnosis code. Submitting a 92004 along with the 367.1 myopia code will result in a claim denial and the medical carrier will not pay you. This happens because many medical insurance companies do not cover refractive care. (The reasons why are discussed below.) Submitting a 92000 eye exam procedure code with a refractive diagnosis to the patients medical carrier can affect your bottom line, but you will not be accused of fraud for this mistake during an audit.
2. Submitting a 92000 eye exam code that includes a refraction to a medical carrier. This is a form of insurance fraud known as bundling, which is the inclusion of certain procedures as a part of another separate billable procedure. However, unlike refraction, not every extra optometric test is prohibited from inclusion in eye exams. For example, my local Medicare carrier publishes a Local Coverage Determination (LCD) for the 92000 eye exam codes, which approves the following tests to be performed with eye exams, but without any increase in the level of reimbursement:
Potential acuity meter.
Transillumination of iris and globe.
Tear film adequacy.
Many O.D.s make the mistake of bundling an eye exam with refraction because not bundling a 92000 eye exam code with a refraction runs counter to our traditional optometric way of thinking. For example, many state health care assistance programs, such as Medicaid, still include refraction in the 92000 codes. Additionally, some professional organizations have encouraged us to bundle refractions. Some state boards, optometric societies and the American Optometric Association have published clinical care guidelines that list refraction as an integral part of a comprehensive eye examination.
Why Refraction Cannot Be Bundled
Medical carriers are opposed to including refraction in medical eye exams because they do not consider refraction necessary to keep eyes healthy. Never mind the fact that most pathology is found during visits in which refraction is performed.
Medical carriers are also opposed to including refraction in medical eye exams to control costs. If they allowed refractions to be bundled with exam codes, patients would always use their medical insurance for routine eye care instead of their vision insurance. Insurance companies would then have to pay us higher medical reimbursements. With the reimbursement for a medical 92004 code hovering around $130, its easy to see why some doctors dont mind throwing in a free refraction if it means getting paid at a rate much higher than vision plans offer, which typically range from $39 to $79.
From a medical carriers viewpoint, the practitioner who includes refraction at no charge essentially baits patients in for a routine eye exam and then bills the medical carrier for the costs. Therefore, medical carriers mandate a separate charge for refraction to prevent practitioners from billing medical insurance for a non-covered service. This same principle is behind the mandatory collection of co-pays, which deter patients from abusing health care benefits. Eye care professionals who fail to charge patients for refraction are as guilty as practitioners who routinely waive co-pays to attract higher patient volumes.
The Battle Rages On
There has always been a financial tug of war between third-party payers and practitioners because the insurance companies want to pay as little money as possible to practitioners.
Over a decade ago, the federal government intervened in this battle by establishing an objective system of valuation for all professional services, which today is known as the Resource Based Relative Value System (RBRVS). This system establishes definitions for each professional service. Local Medicare carriers further refined the definitions for eye exams by issuing an LCD for the 92000 code set.
The definitions and rules for billing refraction can certainly confuse the medical billing freshman. For example, page 353 of the 2005 Current Procedural Terminology (CPT) book states: refractionshould be separately reported. Prescription of lenses, when required, is included in 92015. This 92015 code is described on the next page as, Determination of refractive state. Furthermore, my local Medicare carrier includes the following language in its LCD for eye exam codes: Refraction, the determination of the refractive state, continues to be a non-covered service and is not included in the eye (92000) or Evaluation and Management (E/M) codes. Refractive services should be coded separately as 92015.
To clarify this confusion, a new patient who undergoes an exam and refraction should be billed as follows:
New patient, Comprehensive exam: 92004 ($122)
Determination of refractive state: 92015 ($69)
Total fee: $191
As medical coding and billing become better understood, expect to see much needed modifications of eye exam guidelines from our professional organizations. In the meantime, we must be careful to follow the rules in medical eye exam billing. Failure to charge patients for refractions will be discovered in an audit. Fines, penalties and chargebacks will then far exceed the original reimbursements.
I encourage every O.D. to learn about medical billing and coding. Although vision plans try to dress themselves up as true third-party payers, their reimbursements are unacceptable. Think of every vision plan contract as an umbilical cord to be cut before growing up into your full potential as a legitimate medical professional. As long as we continue to accept reimbursements from vision plans and private pay patients that are a fraction of the objectively-derived RBRVS values, the medical carriers will effectively keep us out of the medical billing system.
Dr. Dean is in private practice in Albuquerque, N.M. He also lectures and does on-site consulting for practices wanting to transition to medical eye exam billing.