Coding & Reimbursement

Refractions: Questions on the most common test

By Suzanne Corcoran

Refraction is the single most common diagnostic test in eye care. Still, questions arise about it.

Q When may we charge for refraction?

A Charge for refraction when the test is completed and a prescription given to the patient. We suggest you not charge if the refraction is incomplete or you don't give the patient a prescription. For example, a prescription is generally not indicated for a diabetic patient with uncontrolled blood sugar and rapidly changing refractive error.

Q Must we dispense an Rx for eyeglasses?

A In 1978, the Federal Trade Commission (FTC) published its Prescription Release Rule that: “… require an eye care practitioner (an optometrist or ophthalmologist) to provide a patient, immediately after completion of an eye examination, with a free copy of his or her eyeglass prescription.”¹ This means the patient is entitled to a copy of the final prescription even if the results of the refraction are unchanged from a prior visit.

Q What is Medicare's policy concerning refractions?

A Medicare does not cover refractions for any reason. The Medicare Benefit Policy Manual Chapter 16 §90 states: “Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever purpose performed … are not covered … Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.”

You do not need an ABN for items or services statutorily non-covered by Medicare, although you may use it if you wish to avoid confusion. Some practices make up their own discussion about refractions. Charges for non-covered services may be collected at the time of service. We strongly encourage this.

Q Must I include refractions on claims for Medicare beneficiaries?

A No, but in the interest of financial transparency and clarity, it is a good idea to itemize all charges on the claim form. For Medicare beneficiaries, append modifier GY to CPT 92015 as a mechanism to emphasize this point. Modifier GY means “not a Medicare benefit.” If this modifier is not used, Medicare carriers have computer edits to reject all claims for 92015, although it is more precise to include the modifier rather than omit it.

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

A Medicare never bundles refractions with the associated exam charge. Vision plans, some primate insurance 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, although Medicare does not accept these codes:

• S0620 Routine ophthalmological examination including refraction, new patient.
• S0621 Routine ophthalmological examination including refraction, established patient.

1. Advertising of Ophthalmic Goods and Services, Statement of Basis and Purpose and Final Trade Regulation Rule, 43 FR 23992, 23998 (June 2, 1978).