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Thread: Billing for refraction?

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    Billing for refraction?

    Split? Or not to split? That is the question!!!There seems to be some sort of confusion as to whether a refraction is included in certain ophthalmic codes, or if it has to split out. Apparently, Medicare requires it to be split out, but BCBS feels this is unbundling. How are the rest of you dealing with keeping this staight, and knowing when to split, or not?

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    If one reads the Eye Care I ruling it states: "The written Rx must be given to the patient in writing whether requested or not at time of examination." This would imply that one cannot do an examination without refraction.

    Now medicare's stance is different, don't know how one resolves this.

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    Bad address email on file NC-OD's Avatar
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    There are ten elements of an eye exam:

    1. Confrontation fields
    2 Eyelids and Adnexa
    3 Ocular mobility
    4 Pupils/Iris
    5 Cornea
    6 Anterior chamber
    7 Lens
    8 Intraocular pressure
    9 Retina
    10 Optic Disc

    A comprehensive exam consists of 8 or more of the above elements
    An intermediate exam consists of 3 to 7 elements.

    That's it. Refraction is not included at all. It is 100% seperate and optional. In fact you can do comprehensive exams all day long and never touch a phoropter.

    Refraction should be billed seperately. BCBS, UNHC, Tricare and others pay upwards of $50 for the refraction over the exam fee (and UNHC reimburses so poorly you should take what they give you). Medicare has, in the past, required you to bill the refaction to the patient but has since relaxed that requirement. It is optional but, of course, you must bill everyone equally.

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    NC-OD


    Can a patient call in and schedule for a "refraction" and not undergo or pay for all of the other elements of "a complete eye exam?'

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    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by chip anderson
    NC-OD


    Can a patient call in and schedule for a "refraction" and not undergo or pay for all of the other elements of "a complete eye exam?'
    Not in my office. I won't accept the liability. I'm too scared of the ambulance chasers. :o
    Last edited by NC-OD; 08-05-2005 at 04:30 PM.

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    OptiBoard Professional UFRich's Avatar
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    We bill the refraction seperately in our office for the refraction. NC-OD, I am finding BCBS of FL denying payment for the refraction and considering it pt. resp. Do you thinking I may be billing incorrectly? Thanks for any info.
    UFRICH:cheers:

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    That is essentially the same problem we are running into in my office as well. For medicare.we are to split the refraction out, docter;s direct as well. however, BCBS will not pay the speperate refraction, we have toroll the fee fro the refraction into the exam fee. What NC-OD says makes perfect sense, but it seems to be impossible to apply. Is there a different way to bill if the exam is billed under medical? If routine, does the refraction then become part of the "package"???

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    Refraction is never part of the eye exam. It is not covered by most insurances, never by Medicare and is always considered seperate. I dread the day when it will be considered bundled into a complete eye exam. On that day we will all lose a lot of our revenue. We charge $29 additional for a refraction and every patient is informed about that upfront.

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    That is what i thought, however, we have been adding the cost of the refraction to the eye exam, and billing the total combined cost of the two to BCBS and United Health. This was based on the information given to us by our last insurance person, who says she called the seperate insur. companies and asked them how we were to do it. So we are incorrect in doing so? ~sigh~

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    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by UFRich
    We bill the refraction seperately in our office for the refraction. NC-OD, I am finding BCBS of FL denying payment for the refraction and considering it pt. resp. Do you thinking I may be billing incorrectly? Thanks for any info.
    My insurance person, who I sleep with (and I'm married to her) tells me that most BCBS plans here in NC will pay us for refractions when billed seperately (92004 and 92015). Sorry, I don't have the specifics on which BCBS plans will pay and which won't. My theory is that it really depends on what kind of 8th grade graduate handles the claims as they come in.

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    Just a thought: But when a patient calls you and wants an eye exam, unless there is pain, puss or loss of vision, what the patient wants is a refraction, the other benefits, i.e. screening for disease are just co-incidental from the patient's prespective.

    When a patient comes in for glasses, he usually wants to see better, she wants more style and all the other add-on's, latest no-line, coatings, etc are also just co-incidental.

    Chip
    But, then I am not in Beverly Hills.

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    Quote Originally Posted by chip anderson
    Just a thought: But when a patient calls you and wants an eye exam, unless there is pain, puss or loss of vision, what the patient wants is a refraction, the other benefits, i.e. screening for disease are just co-incidental from the patient's prespective.

    When a patient comes in for glasses, he usually wants to see better, she wants more style and all the other add-on's, latest no-line, coatings, etc are also just co-incidental.

    Chip
    But, then I am not in Beverly Hills.
    Ah so..very true, but the desire for a refraction often indicates decreased acuity, usually from causes other than refractive error. Better to provide that comp. ophth. exam, explain any vision loss to pt, so they dont return a week later ( with a blood sugar of 300!!!*L*) complaining about "our" Rx and "your" specs!!!
    Also, don't underestimate the pt's need for all the bells and whistles where their specs are concerned. Of course they dont want those, not yet anyway!!! I personally have so many "optical accoutrements" on my specs I am seriously rethinking my need for eyeballs!!LOL.

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    OptiBoard Professional UFRich's Avatar
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    NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.
    UFRICH:cheers:

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    UFRrich: You people have just established that the refraction is not part of the important medical exam. So why shouldn't it be cheapened. It hasn't been too long since a "complete eye exam" by an MD including refraction was $15~$35 if no items requireing medical attention were found.

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    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by UFRich
    NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.
    I think I mentioned before. United Health Care is absolutely the work plan I deal with (I don't take any vision plans). They deny refractions 100% of the time but will pay when we spend 45 minutes on the phone with them as they admit they "made a mistake".

    Then we repeat the process the next time:hammer: They should be in prison for fraud.

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    OptiBoard Professional UFRich's Avatar
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    Quote Originally Posted by chip anderson
    It hasn't been too long since a "complete eye exam" by an MD including refraction was $15~$35 if no items requireing medical attention were found.
    I am sure NC-OD can back this up. Our OD may perform 1 out of 100 exams that have no medical diagnosis. If the ODis performing a "complete eye exam" they will almost surely find a medical diagnosis, which could be as simlpe as dry eye. This would also require the Dr. spend more than 15 min in the exam room with the pt. Unfortunately, the are OD's kicking out Rx's in 15 min or less and only performing a refraction in most cases and telling the pt they have had a "complete eye exam", when the could get the same result from an auto refractor.

    Quote Originally Posted by chip anderson
    You people have just established that the refraction is not part of the important medical exam.
    Its not that the refraction is not part of the "important medical exam", insurance companies (todays mafia) do not consider it part of the "comprehensive eye exam".

    Ultimately it comes down to why you are in business. If you are there to provide a quality medical service, then you must spend alot of time explaining to pts. why your fees are more than the guy down the street who is just doing refraction.
    UFRICH:cheers:

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    URich:

    Precisely my point, a medical diagnosis (before insurance companies were involve) including "dry eye" was seldom found in an examination in years past. Now that O.D.'s can make "medical diagnoses" and M.D.'s are out for every buck that exists. Every patient has a "condition". Every medicaid, every medicare patient needs glasses. Even though the incidence of +0.50 -0.50 x whatever is probably 1000% higher than in years past. We have all become corrupted and I don't think it will ever end.

    Chip

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    OptiBoard Professional UFRich's Avatar
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    You are probably right Chip. I am sure there are many OD's only concerned with max billing. I believe in my OD and have gone around with him many times for not prescribing glasses when the optical needed sales. Ultimately I agree with him to not give somone something they dont need. The only way back is to educate the public of the need for quality medical eyecare and set fees accordingly. Our cash pay eye exam is $89, and we have very few complaints after the OD spends most of an hour with them. They are educated as to the completness of the exam they just had. We would rather do cash exams all day over ins. billing, even though we can get more money from the ins. companies.
    UFRICH:cheers:

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    Just An Optician jediron1's Avatar
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    UFRich
    NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.[/QUOTE]

    Would the name less one's be Sears, Costco, Sam's ect ect.?Just had to ask!

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    Bad address email on file fvc2020's Avatar
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    Good Morning everyone


    I do all the billing in my office and never to I not know who is paying refractions and who are not. With the exception of Medicare and Eyemed(who never pay the refraction), I get paid on it everytime. My staff calls and veifies routine vision coverage, medical office visits, if there is other insurance we need to know about. We do alot of vsp, bcbs of any state, health partners, medica, UHC(who will pay the refractions after I personally provide proof it's listed in there benefit package). I am even paid refractions on all of my medical assistance patients. If you are not getting paid you need to see why. We do bill seperatly using 92004 or 92014, with of course 92015 for refractions. Usually never a problem. As for doctors finding medically issues, I have yet to have my doctor find one just so we can get paid more. We bill the fullest amount that we can, so it makes no difference. Does she find medical issues? Of course, but routine is routine.

    I have learned that taking care of the patient to the fullest is my doctor thing. We discuss with patient all our findings and let me say with pride our exams run 30-45 per person. She will not give glasses just to make money,even when I ask her to. We don't bill for the heck of it.

    Just my thoughts on the subject:)

    Christina

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    The majority of PPO's will not pay for refractions unless there is a vision plan bundled into their insurance. My office deals almost exclusively with PPO's and Medicare and we have found that most PPO's don't cover refractions. It's possible that Christina is having "no problem" with collecting refraction fees because their office selects for insurances with vision plans. Or perhaps in an optometric setting the patients have self selected themselves to see an optometrist only when they're sure they have a vision plan. However, I can assure you that with PPO's you never know who is going to cover it and who will not (many many don't).

    Ilan

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    I have an interesting one where the MD billed a medical e/m 99213 ($75) and a refraction ($25). The carrier keyed the claim as $0 for the 99213 and then applied the cost of the office visit to the refraction which they of course denied saying that routine vision is not a covered benefit. They're saying that you can't bill an OV with a refraction b/c they are one in the same... Am I missing something? The dx was Amblyopia.

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    Should be one and the same. Just now that some carriers now have a new box to check some prescribers are trying to make more money out of it.

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    Actually, I think its more in error to assume or want all eye exams to be the same.

    More should be done to educate the patient about what is being done and how that may differ from a "routine" exam.

    I know, most people show up to get glasses, right?

    Yesterday I had a dude ask me if these new glasses were going to correct his color vision. What are they teaching people in these mandated vision self-diagnosis classes?

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