CODING & REIMBURSEMENT

The vision vs. medical conundrum

By Suzanne Corcoran

Patients, as well as staff, are often confused about whether an exam qualifies as a vision exam or a medical exam. Here are answers to some common questions.

Q. If a patient has both medical and vision insurance, which is primary?

A. It depends on the reason for the visit from the patient’s perspective. Bill the medical plan for exams for medical care, evaluation of a complaint, or to follow an existing medical condition. Bill exams to check vision, screen for disease, or update eyeglasses or contact lenses to the patient’s vision plan or the patient himself.

Q. Does Medicare cover “routine” and “annual” exams?

A. By law, Medicare does not pay for routine vision exams. Beneficiaries can choose to have an “annual exam,” but they will be responsible for payment, although some may have private insurance that covers the exam.

Q. When a patient comes for a routine vision exam and we find pathology, may we bill the medical plan?

A. 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. Address the incidental finding of pathology on a return visit. The practice can bill subsequent exams to monitor or treat the pathology to the medical plan.

Q. Is it ever possible to bill both medical and vision insurance?

A. Sometimes. 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?

A. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes rules for “standard code sets” that 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 contact lenses. Medicare does not accept these codes, but other plans may.

Q. How can we reduce confusion with patients on this subject?

A. Start by determining the patient’s reason for the visit during the initial call for an appointment. When the patient arrives at your office, confirm the reason for the visit. Some practices use colored alerts so the staff and physicians know 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?

A. Tactfully, but firmly, decline to file an incorrect claim. Patients often don’t understand their insurance coverage; they may be disconcerted to find 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, assessment, plan) then explain how you addressed the patient’s needs. Review the cogent guidelines of the patient’s insurance plan. This should at least help the patient understand your refusal.