‘Ask the Codeheads’: Choosing codes for reporting medical and non-medical eye examinations
September 23, 2010Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant
Q: I’ve been getting mixed signals…Some insurers reimburse for refraction and others require that refraction is lumped in with the office visit. I bill all my private pay patients the visit plus refraction, but now I’m confused. Help?!
A: In my opinion, refraction should be billed every time it is performed. It is a separate service, has had its own code since 1993 and has not been included in the Current Procedural Terminology (CPT© American Medical Association) definition of any office visit codes since 1992. 1992 is a long time ago.
In my experience, most insurers, including Medicare, respect CPT definitions and permit ODs and OMDs to bill for the visit and the refraction separately.
If the insurer does not cover refraction, they permit doctors (or more accurately, expect doctors) to bill the patient.
The only time you cannot split out the refraction is when you are contracted with an insurer that ignores CPT copyright restrictions and requires you to lump refraction with the visit code.
In all other cases, refraction should be reported separately every time it is done.
Q: I’ve been trying to figure out how to bill for eye examinations for patients with medical reasons for their visits, those that don’t have medical reasons for their visits, those who have medical insurance, those who have vision plans, those who are private pay, etc. Any suggestions, oh, pointy-headed one?
A: First, the decision as to which codes to use should never be based on whether the patient is insured or self-pay.
The vast majority of insurers’ contracts require you to bill the insurer just as you would bill a private-pay patient.
It is important to set your fees at levels that are balanced so that you are respecting the patients’ ability to pay while also recognizing that many of your services are important medical services and are inherently valuable to the patient, the insurer and the health care system. You may end up with a fee schedule that is slightly lower than you believe it should be (in order to keep private-pay patients happy) while being a little higher than private-pay patients want to pay (in order to be properly reimbursed for medical care). You may get some complaints about your fees, but that will be true no matter how low or how high they are. The key is to develop fees you are comfortable with, explain them carefully to your staff, and apply them as uniformly as possible.
Q: Can you please clarify the phrase “initiation or continuation of diagnostic or therapeutic program,” used for billing the 92002/92012 and 92004/92014? I heard one expert say that means the prescription of a medication or referral to a specialist. Another said ‘monitoring cataracts in one year’ qualifies. This category has me unsure whether to bill a 99214 or 92014 when the plan is to monitor cataracts and no medical treatment is initiated.
A: Current Procedural Services, the key reference for choosing codes for reporting services, includes a requirement for “Initiation of diagnostic and treatment program” in the definitions for 92004/92014 and 92002/ 92012 office visits. The definition also includes an example for the requirement, although there are very significant differences among doctors and auditors as to what is required. In my opinion, every eye examination concludes with a summary of diagnoses and management options…that’s just how we do it.
Most of those diagnoses and management options can be considered part of the “initiation of diagnostic and treatment program” for the patient. I assume these to include prescription of medications, spectacles, contact lenses, low vision aids, vision therapy, instructions to return to the office for follow-up care or re-examination at a future date, referral to another health care provider, instructions for lid scrubs, ordering additional diagnostic tests, recording the diagnoses pertinent to the day’s visit, etc. I’m guessing a typical eye doctor’s list would have 15 to 20 items on it.
Some insurance companies read the example provided in the CPT and, because it includes “prescription of medicine,” they assume that you can only use the 920xx codes if you’ve written a new pharmaceutical prescription. I believe that interpretation is way too narrow.
The key is to have a list in your practice that matches the language of the definition in the CPT in your opinion and to adhere to that list. Then, in the case you are audited, you can refer back to your in-office protocol, explain it to the auditor and probably do just fine.
My understanding is that we need to have one foes for each service period. That is our highest fee. We can discount, and we all do this with each insurance or vision plan that we participate in.
I know of no reason that we can not discount a fee for any person that we deem “in ndeed”.
Every hospital I have dealt with in the last few years offered a big discount if I paid my bill up front. In one case my deductible was reduced by 50% for paying prior to the procedure.
Does anyone know if there is a special CMS rule that pemits hospitals to discount fees for any person paying in full on day of service? Do CMS guidelines permit OD’s to discount fees when services are paid, or prepaid, in full on day of service? Would doing so jeopardize our reimbursement rate with CMS?
One time discounts are all right for any patient for any reason. However, if you develop a policy to provide discounts for all patients under certain circumstances, the only such discount is called prompt pay, meaning that the patient has paid in full on the day the services were received. Such prompt pay discounts are set by each practice, with some consultants suggesting the discount be no larger than about 10% while others suggest much higher discounts. I suggest the discount should not exceed 15-20%. Each office has to consider lots of factors when establishing discounts, such as net income. Also, anyone paying in full on the day the services are received gets the discount. Medicare and other insurers either already discount below the prompt pay amount and/or they will never pay on the day of service, so prompt pay discounts generally only apply to patients paying for their own services. Thanks, Dr. Chuck Brownlow