Everyone knows about refractions — it’s the most common diagnostic test in all of eye care. However, there are still some aspects that you may not know.

Q. First, the basics. What is 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 clearest vision. For young patients, retinoscopy is used. After the measurements are made, the physician decides on the appropriate prescription.

Q. What is Medicare’s policy concerning refractions?

A. Medicare does not cover refractions for any reason. The Medicare Benefit Policy Manual (MBPM) 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 an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.” The statutory authority for this regulation is the Social Security Act §1862 [42 USC 1395y] (7), which excludes Medicare coverage for these services.

Q. When may we charge for a refraction?

A. A charge for a refraction is merited when the test is completed and a prescription is given to the patient. If the refraction is incomplete or the patient is not given a prescription, then we do not suggest a charge. For example, the refraction is incomplete if a technician performs an autorefraction as a rough starting point, but the physician does not refine the measurements to reach a final determination of refractive error. Sometimes the physician chooses not to give 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 a prescription?

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. The [Ophthalmic Practice] Rules also prohibit an eye care practitioner from conditioning the availability of an eye examination on a requirement that the patient agree to purchase ophthalmic goods from the practitioner. The Rules further prohibit an eye care practitioner from making certain disclaimers and waivers of liability.”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. However, if the refraction is incomplete, then no final script exists to give the patient and no separate charge should be made.

Q. Is there a set or maximum amount we may charge?

A. Most practices charge for refractions and the fees vary widely around the country — in our experience at Corcoran, they range from $5-$90, with the average around $35. Although not covered, Medicare assigns RVUs to 92015. In 2018, the national Medicare value is about $20.

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 commercial insurance plans and Medicaid plans will often bundle it with a covered exam; check the policies of these payers. Refractions are bundled into the services identified with the following HCPCS codes, although these codes are not accepted by Medicare: S0620 (Routine ophthalmological examination including refraction, new patient) and S0621 (… established patient).

Q. Is an ABN required in order to collect from the beneficiary?

A. No. As noted above, the regulation and statute exclude Part B Medicare coverage of routine eye exams and refractions. You do not need an ABN for items or services that are statutorily (by law) non-covered by Medicare. At your discretion, you may choose to notify beneficiaries that these services are never covered. Charges for non-covered services, such as refractions, may be collected at the time of service.

For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services.

Q. Must I include refractions on claims for Medicare beneficiaries?

A. No, but we recommend it. Your patients get a remittance advice showing what was charged and paid. When they see the refraction denied as non-covered, it helps to reinforce what you told them. OM

REFERENCE

1. Advertising of Ophthalmic Goods and Services, Statement of Basis and Purpose and Final Trade Regulation Rule, 43 FR 23992, 23998 (June 2, 1978). Reviewed and confirmed, Federal Register, Vol.69, No.23, 5451, 5455 (Feb. 4, 2004). www.federalregister.gov/documents/2004/02/04/04-2234/ophthalmic-practice-rules . Accessed June 28, 2018.

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