coding & reimbursement
Refractions and Reimbursement
You can't bill Medicare for this test, but it can still affect your income.

Refraction is the most common diagnostic test in eye care, but questions about the possibility of reimbursement still arise. Here are some frequently asked questions -- and their answers.

Q: How do refractions affect Medicare reimbursement? As you know, by law, Medicare doesn't cover refractive services. However, it's important to note that if a Medicare patient presents with only a refractive complaint (e.g., "I need new glasses"), the exam is also not covered, even if you find disease during the exam:

"The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition."

Q: What about non-Medicare payers like HMOs and PPOs? Whether other third-party payers cover refractions is a matter of contract. If their policy isn't clear when you sign up, pursue the question until you get an answer. Being able to collect your usual refraction fee in addition to the exam may determine whether or not you can afford to accept a plan.

Many payers have multiple plans, some of which bundle the refraction. Be sure to find out which of your plans allow you to collect separately for refractions, and make sure your office staff has this information. Otherwise, you may be leaving money on the table.

Q: Once we set a fee for refraction, do we have to charge everyone the same amount? Medicare has no requirements in this regard; Medicare doesn't even care if you decide not to charge.

Private insurers may have different rules. (Check your contracts.)

Q: Can a technician perform refractions when the physician is out of the office? Medicare doesn't publish an instruction about supervision of refractions because this service isn't covered. However, we can infer that performing this service requires the presence of the physician for a number of good reasons:

► Technicians aren't licensed to perform refractions and can't provide patients with a prescription. Only an ophthalmologist or optometrist is licensed to render this service.

► It's pointless for a technician to perform "refractometry" without a physician present. Few patients would want to return for another visit just so the physician could use the refractometry findings to complete the refraction.

► According to the Federal Trade Commission's Prescription Release Rule, any time a refraction is done, the patient is entitled to a copy of the eyeglass prescription. The technician can't provide it.

► As a professional liability and state licensure issue, a physician shouldn't let a technician perform refractometry without his/her presence. We are aware of at least one case where the board of medicine vigorously pursued an ophthalmologist because his technicians did refractions. (This case resulted from a complaint by another doctor in the same community.)

Given these factors, the common sense answer to this question is that refraction requires direct supervision. (Note: A technician may perform lensometry to make sure a prescription was filled correctly by an optician. Checking glasses is not the same as refractometry or refraction, and it doesn't require the presence of the physician.)

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.