coding & reimbursement
Medical Exam or Vision Exam?
Knowing which to bill can be tough. Here's help.

By Suzanne L. Corcoran, C.O.E.

Staff and patients are often confused about whether an exam qualifies as a vision exam or a medical exam. Here are answers to common questions.

Q: If a patient has both medical and vision insurance, which is primary? It depends on the reason for the visit, from the patient's perspective. Exams for medical care, evaluation of a complaint, or to follow an existing medical condition should be billed to the medical plan. Exams to check vision, screen for disease, or update eyeglasses or contact lenses should be billed to the patient or the patient's vision plan.

Q: Does Medicare cover "routine" and "annual" exams? By law, Medicare doesn't pay for routine vision exams. Medicare beneficiaries can choose to have an "annual exam," but they will be responsible for payment. (Some may have private major medical insurance that covers the exam.)

Q: If a patient comes in for a routine vision exam and we find pathology, can we bill the medical plan? Unless you find an urgent or emergent medical condition, the chief complaint should comport with the primary diagnosis and determine coverage. For example, the chart may read: "Here for routine eye exam and new glasses" with a corresponding diagnosis of refractive error. The incidental finding of pathology should be addressed on a return visit. (Subsequent exams to monitor or treat the pathology can be billed to the medical plan.)

In the event of an urgent or emergent medical condition, the medical plan should be primary.

Q: Is it ever possible to bill both medical and vision insurance on the same date? It may be. Some vision plans will cover a refraction even when the visit is covered by the medical plan. If the vision plan allows it, the claim should be submitted with the appropriate medical diagnosis associated with the visit and a refractive diagnosis mated to the refraction.

Q: What happened to the local codes that used to describe routine eye exams? The Health Insurance Portability and Account-ability Act of 1996 (HIPAA) includes rules for "standard code sets," which eliminated payers' ability to create and use their own codes to describe services provided. Some payers replaced their routine eye exam codes with HCPCS codes.

HCPCS codes S0620 (Routine ophthalmological examination including refraction; new patient) and S0621 (...; established patient) specifically describe routine eye exams, including refraction. These codes are appropriate for healthy patients who come in for a regular check-up and for new glasses or contacts. (Medicare doesn't accept these codes, but other plans may.)

Q: How can we reduce confusion with patients on this subject? Start by determining coverage on the phone during the initial call for an appointment. When the patient arrives at your office, confirm the reason for the visit. Some practices place stamps or stickers on the chart to alert the technicians and physicians to the reason for the visit and the limitations of coverage.

Q: How should we respond if a patient asks us to modify a claim to avoid personal financial responsibility? Tactfully, but firmly, decline to file an incorrect claim. Patients may be disconcerted when they find that their insurance doesn't pay for a service they want.

If this happens, review the medical record with particular attention to the crucial entries (i.e., chief complaint, history, assessment, plan) and then explain how you addressed the patient's needs. Review the cogent guidelines of the patient's vision and medical plans. Your explanation should at least help the patient understand the reasons for your refusal.

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