coding & reimbursement
Documentation and Billing for Refraction
Several factors can make this common procedure complex.

Any discussion of refraction (CPT 92015) is bound to engender a strong response from patients and eyecare professionals. By law, Medicare does not pay for this service, for any reason, and beneficiaries often complain about this out-of-pocket expense. Although refraction is a separate diagnostic test, many other payers treat it as an incidental part of an eye exam. Some eyecare professionals are reluctant to charge for refractions, believing that any complete eye exam incorporates this test. So what's the whole story with refractions?

Q. What is a refraction?

A: A refraction determines an eye's refractive error and the best corrective lenses to be prescribed. It is performed using a series of test lenses in graded powers to determine which provide the sharpest, clearest vision. If the eyecare professional arrives at a trustworthy conclusion that can be given to the patient, without causing harm or needless expense, then the refraction is complete and a charge is merited. Conversely, an inconclusive, unreliable or unsatisfactory result following testing should not be dispensed and the refraction is incomplete.

► A prescription is tangible evidence that a refraction was completed. It requires the signature of an ophthalmologist or optometrist — technicians cannot sign prescriptions. Under Medicare regulations for covered postcataract eyeglasses, the prescription requires an original ink signature and date handwritten by the physician. While the use of signature stamps is commonplace, we discourage their use. In a recent Medicare memorandum (Transmittal 59), it says: "Providers using alternative signature methods (e.g., a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods."

► A prescription does not have to be different from the current eyeglasses to be worthwhile. The patient may wish to purchase replacement glasses, an additional pair of glasses, specialty eyewear, or keep a copy of the prescription handy in case of emergencies.

Q. Are we required to give the patient a copy of the prescription?

The Federal Trade Commission Prescription Release Rule states, "Requires eye doctors to give patients their eyeglass prescription at no extra cost immediately after an exam that includes a refraction. The eye doctor may withhold the eyeglass prescription until the patient has paid for his/her eye exam, but only if the eye doctor requires immediate payment whether or not a prescription is needed."

Thus, a patient is entitled to a copy of the final prescription, even if the results of the refraction are unchanged from a prior visit. However, if the refraction is incomplete, no final prescription exists to give the patient and no separate charge should be made.

For the sake of courtesy and good patient relations, Medicare beneficiaries should be made aware of their financial responsibility for refractions, usually by posting a discreet sign in the reception area and incorporating a clause in your patient registration document(s).

Q. What should we charge?

The vast majority (>90%) of our clients charge for a refraction as a separate fee from the eye exam or consultation. Fees range from $5 to $120, and the average is $25 to $40.

Conclusion

A refraction is the most common ancillary diagnostic test associated with an eye exam or consultation and demands attention as a matter of policy. Further, the resentment of Medicare beneficiaries toward out-of-pocket expenses for refractions guarantees that your policy will be challenged often at the check-out desk, so it is important to be clear on a few points. First, FDA regulations entitle the patient to a copy of the prescription. Second, a charge is merited when a refraction is complete and a prescription is given. Finally, patients should be made aware of their financial responsibility.

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