Coding & Reimbursement

Getting to the Bottom of Asthenopia

By Suzanne L. Corcoran, COE

If you have patients who engage in a lot of near work, you probably will have to deal with asthenopia. Here is what you need to know in order to recognize, test and bill for it.

Q. What is asthenopia, and why is it a problem for some people?

A. A patient with asthenopia may complain about eye strain, blurred vision, intermittent double vision, headaches, or pain in and around the eyes. Such complaints are usually related to near vision work or prolonged periods of reading or studying, although they may also occur after driving and other tedious visual tasks. Typically, symptoms are not present on awakening in the morning.

The principal causes of asthenopia are a sustained effort to maintain fusion in the presence of an oculomotor imbalance (muscular asthenopia), an uncorrected refractive error (refractive asthenopia), or accommodative insufficiency.

Symptoms caused by asthenopia are frequently not addressed in the usual eye examination, and patients may repeatedly purchase eyewear hoping to solve the problem.

Q. How does testing help treat these patients?

A. Patients with binocularity deficiencies can be helped with spectacle lenses that incorporate prism to eliminate asthenopic symptoms. This is particular helpful for presbyopic patients who experience difficulty with computer screens.

Q. Who pays for the testing?

A. Testing for asthenopia is a refractive exam that involves evaluating convergence and accommodation. Use CPT 92015 (determination of refractive state) to report evaluation of phorias concurrently with other refractive errors. When the time and resources involved to accomplish this “super” refraction is very much greater than would otherwise be typical, append modifier 22 (increased procedural services) to the CPT code.

This testing is covered by vision plans and some health plans that pay for eye exams and refractions for the purpose of prescribing eyeglasses and contact lenses.

Q. Should we make a separate charge specifically for testing convergence and accommodation?

A. Not usually. The evaluation of binocularity deficiencies is one aspect of a refraction. When you find tropias, often associated with diplopia and strabismus, then additional testing may be necessary and a separate charge for sensorimotor exam (CPT 92060) may be justified.

Although not covered, Medicare assigns RVUs to 92015. In 2011, the national Medicare value is $26.84. Professional fees for refractions vary widely ($5-$90) and the average is about $35. When testing specifically for convergence and accommodation accompanies determination of refractive error with a phoropter or similar instrument, a higher-than-average fee may be justified for the added work involved.

Q. What constitutes a refraction?

A. Clinically, refraction means determination of the eyes’ refractive error and prescribing the appropriate corrective lenses to ameliorate the defect. In patients capable of responding to choices, the task is accomplished by presenting the patient with a series of test lenses in graded powers to determine which provide the sharpest, clearest vision. After the measurements are made, the ophthalmologist or optometrist decides on the appropriate prescription.

Q. Are refractions ever considered part of the office visit or eye exam?

A. Medicare never bundles refractions with the associated exam charge. Occasionally vision plans and Medicaid plans will bundle this test with a covered exam. Check the policies of these payers. Additionally, refractions are bundled into the services identified with the following HCPCS codes:

S0620 Routine ophthalmological examination including refraction, new patient

S0621 Routine ophthalmological examination including refraction, established patient

Q. How frequently may we charge for a refraction?

A. Unless specified by a vision plan, there is no limit to the number of refractions that can be done or charged to a beneficiary. Medical necessity is certainly an important aspect to consider, as is patient relations. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.