One thing seems clear when you put all of the legal, moral and ethical issues aside, most MD’s and OD’s decision whether to bill or not bill will be based on their pecuniary interests. We use the “system” when it adds to the income and ignore the “system” when it costs us money. I am not being judgmental, just observant.
Rant mode :ON:Originally Posted by chip anderson
Good point Chip. I do only need one (1) patient to buy the stuff at the paint store, go blind, claim I gave them the wrong directions, and sue me blind. :( I recommend standard non-prescription remedies all the time, but only things I'm comfortable with, and only to certain patients I can trust.
That is essentially the point. The world HAS changed. I just listened to a lecture on malpractice today (how timely), and they provide some pretty clear examples on just how crazy the whole system has gotten. Unfortunately, we can't practice in our own little bubble and ignore the outside world. Certainly we can't just do everything based on the potential for malpractice, but it is ever present and to think otherwise is foolish.
And Harry, you are perhaps incorrectly integrating every segment of the eye care industry into one huge mass to fit with your idea of whats going on. Some places have always been concerned with pushing people through as quickly as possible, and that isn't going to change no matter what insurance ODs can bill. Others have been billing medicare and other insurances for over 20 years. There are a lot of people who will crash and burn trying to do both.
It is a confusing history, and greatly depends upon who tells it. My take is that its a combination of changing standards of care due to increased technology just as much as it is scope of practice changes. But its mostly interrelated. ODs getting the right to dilate and prescribe medications opened the door for the potential for malpractice. And new technologies that allow for earlier treatment of previously blinding conditions in many cases call for more routine screening and detection. To do otherwise is malpractice and whether you like it or not, we are responsible for their health even though they may ignore it.
Example: Glaucoma. We barely learned about pachymetery in school, but now almost everyone recognizes it as standard of care for a glaucoma suspect. And things are now turning to laser imaging as almost becoming standard. It absurd to think ODs should be required to perform these tests while not be reimbursed, or to think them greedy if they do.
I shouldn't have to tell you all the cost to our health care system if a person goes blind or has a serious visual impairment, but its HUGE, and probably some economist could rationalize all the preventative care offered by eye care providers as more than offsetting this.
Another example is the new anti-vegf drugs that are starting to come out. Just a few years ago there wasn't much that could be done (or done effectively) for ARMD or clinically significant diabetic macular edema. Now, these drugs are literally being tried on almost anything that is related to retinal vascular issues. Just a few short years ago the treatments were nil or barbaric at best. So, what before was "we can't do anything for you" has become, "lets take a closer look at that to decide if this new treatment is right for you." Doesn't imply anywhere in here that I want to inject these drugs, but ODs and ophthalmologists need to be able to detect their presense.
Both these examples are just within the last year or two.
I have several types of patients. But I often get the comment that their eyesight is important to them and they are glad the just got a thorough exam and sat through a dilation.
I also have the ones who expect me to do all of their health care for pennies on the dollar, or what in another setting would be well over $200.
I'll stand by this, eye care is perhaps the cheapest and most easily accessible of all the health care fields. You can get in anytime, and find almost any sucker OD to deal with your hypertensive retinopathy, diabetic retinopathy, thyroid eye disease, cataracts, "mild" glaucoma, dry eye, eye allergies, and still fit them for contacts and write a prescription for less than what most other health professionals charge for a no-show fee.
I don't know why you guys are complaining, there is cheap everywhere. Tons and tons of ODs charge little more than a happy meal for a full exam (including a sacred refraction).
rborach:
I don't know, I have just told people to get what's on the drugstore shelf and an eye dropper. For CL patients one drop per eye in the evening after CL removal. For others it doesn't matter how often they use it, but four times a day should suffice. It is hard to convince people that you are serious (especially ophthalmologists) and usually they will only try it after every thing the doctors have Rx's fails, or drops off in effectiveness.
So far the results have Mirrored Dr. Girrard's almost 100% positive results and one or two that felt it stings a little and quit. No adverse reactions ever. Even works with patients having dry eye and gooey mucous deposits.
Haveing said this I also think "dry eye" is one of the most over diagnosed malladies in medicine. Seems to be much more prelevant now that we have puntum plugs and $450.00 surgical fees to install them. And believe me puntum plugs can cause a whole bunch of problems.
Chip
I believe dry eye syndrome is under diagnosed... and I don't do punctal plugs in my office.
I also believe it is under diagnosed.
Chip, if you think it is overdiagnosed, maybe you could start a trend by cutting back on your diagnosing and prescribing treatment of dry eye.
LADIES AND GENTLEMEN,
My name is Andrew Roy and I own RLR Consulting, more information here: http://optometricbilling.rlrbillingsolutions.com. We have been specializing in Optometric Billing services for over 15 years, specifically in Medicare and Medicaid. Over that time I have learned that different insurances are ficcle when it comes to the issue of billing for refractions and dialations.
So to my clients I give them this general rule:
1.) Medicare considers refraction to be part of a routine eye exam and therefore does not require that it be split out. (ANY ONE THAT TELLS YOU DIFFERENTLY HAS NOT DONE THIER HOMEWORK, IN FACT WHEN BILLED SEPERATELY, THE AUTOMATED SYSTEM WILL TELL YOU IT WAS NOT PAID BECAUSE IT IS CONSIDERED PART OF THE ROUTINE EXAM.)
2.) Because you are not required to bill for refraction seperately that leaves you with a dilemma, if you include the refraction as part of your exam you will only be paid about 80% of your total charge, if you bill seperately, you can charge the patient up front in cash thereby collecting 100% and lowering your patient's deductible for the year.
3.)THEREFORE THE RULE STANDS: BILL THE REFRACTION SEPERATELY AND DO YOUR PATIENTS A FAVOR, THEY WILL THANK YOU IN THE END WHICH WILL ONLY PAY DIVIDENDS TO YOUR PRACTICE IN THE FUTURE.
Nice post. Can I make a few clarifications?
More precisely, Medicare considers refraction a non-covered service.
"Separating out" refraction fees is inapplicable to medically necessary services and all medical carriers since it's never correct to include refraction with an ophthalmological or E/M code. It's like mixing oil and water.
As to reducing deductables, I'm not sure if you're saying that refraction has anything to do with meeting deductables or not. If so, I think non-covered services have no bearing on deductables.
As to collecting for refraction, I'm all with you!!
Generally speaking, no, refraction is not related to deductibles.
However, if you bill for it seperately and report it on the claim as 92015 and then show cash amount collected as the same amount you normally charge for refraction, it is subtracted from the patient's deductible by medicare when they process the claim.
As for refraction being non-covered, this is not true, it is merely considered part of a routine eye exam, and different carriers do treat this differently. IE, Aetna does pay for refractions as well as medicaid and horizon. In general, medicare is really the only carrier that treats Refractions as part of the routine exam.
Mr DRK, I specialize in helping my clients with issues such as this and these words are true to the T. In fact, if there is anything that I can ever help you with, please do not hesitate to call me, 856.364.7229 or post a request for clarification.
I've rarely heard it explained this way. Do you have some documentation to show this, like a medicare .pdf or something similar. It doesn't really seem to make sense the way you describe it. For example, if it is supposed to be included, why are we allowed to charge the patient for it (medicare)?
The key is routine exam!
You bill for medical eye exam!
So refraction could be included in the routine eye exam but not in the medical eye exam!
For someone claiming expert status you seem to have no idea what you are talking about.
Straight from the (Cigna) Medicare website (and based on 13 years of MCR billing experience):
"A refraction is not an element of an intermediate or comprehensive eye exam and is never covered by Medicare. "
http://www.cignagovernmentservices.c...halamogic.html
Medicare doesn't even pay for routine exams.
It doesn't get any clearer than that. Refractions not covered= Patients pay for that part.
Last edited by NC-OD; 06-29-2008 at 10:01 PM.
when Chip posts there’s not a dry eye left in the house…
Excerpt from Review of Optometry 2000
The people at Allergan Pharmaceuticals thought they had a good thing going when they approached the FDA last July for approval to market cyclosporine 0.05% (Restasis) as a treatment for dry eye. The two arms of the phase 3 clinical studies had gone well, demonstrating that the T-lymphocyte inhibitor effectively reduces the signs and symptoms of keratoconjunctivitis sicca with minimal adverse events.
But then something funny happened. The ophthalmic advisory panel for the FDA was less than impressed with Allergan’s clinical data. The panelists issued a so-called “approvable letter” listing several points they wanted the company to address before they would recommend approval. “We have been reviewing the data and looking to see if in fact we could present the data from those studies in a way that would better present our case,” Allergan spokesman Ira Haskell says.
“Unfortunately, the two arms of the phase 3 trial did not completely replicate themselves in terms of the signs and symptoms that reached statistical significance,” investigator Steven E. Wilson, M.D., wrote in a paper presented last September at a Research to Prevent Blindness seminar. One problem was that cyclosporine’s vehicle, a castor oil emulsion, may have worked a little too well in the trials.
“I don’t know that the panel was that impressed that there was that much difference between the drug and the vehicle,” says investigator Stephen Pflugfelder, M.D., who testified before the FDA panel on behalf of Allergan. “The vehicle itself is better than any artificial tear. You know, if they had compared the drug to artificial tears, they would have won hands down, I’m sure.”
Allergan expects to hear back from the FDA by June, Mr. Haskell says. In the meantime, someone should consider packaging castor oil as a treatment for dry eye. Apparently, it’s the next best thing to cyclosporine.—R.M.
Fast forward to this thread:
orangezero: You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide. Chronic issues are no treat to live with. Be careful what you downplay at superfluous.
Chip: Does this mean that elderly sucide could be prevented by the simple cheap application of castor oil drops?
orangezero: Which do you want Chip? Do you want us to spend more time with patients and solve their problems, or do you want to do whats cheapest and what you've always been accustomed to? Its not making money out of thin air, these patients have problems and we now have solutions. How dare we expect them to pay for our expertise, is that what you are contending? I just knew that dry eye thing would get comments.
Chip: Actually Castor Oil four times a day will cure almost every case of keratitus dissicica eventually. Where did I get this? From Dr. Louis Girrard, M.D.
Where did he get it? Back in the late 50's and early 60's anesthesiologists were using anesthesia that kept the patient's eyes open during non-opthalmic surgery. They didn't like the patient's corneas cracking so they carried Castor Oil and dropped it in, the patient could be kept out for hours without corneal damage. Dr. Girrard started trying it on the worst cases of keratitus dissicca which were sent to him while he was chief of Baylor Medical's Ophthalmology Department. It worked.
Why doesn't anyone prescribe this? It's not FDA approved as it's not patentable. Today's doctors are far more afraid of lawyers than intersted in the patient.
orangezero: Endura? Restasis has castor oil?
I don't doubt you or the doctor you mention. However, a perfectly "normal" patient who is having their eyes held open and requires some type of tear shield is a bit different than the numerous other ways patients are affected with what the layman would term "dry eye."
What castor oil are you recommending to your patients?
Honestly Chip, your distain for the average doctor is disheartening. We have feelings too (even the nonMDs you don't consider doctors). The real heartless, out for profit, dudes are in other businesses swindling you out of even greater amounts of money on a daily basis. So many betters ways to bring home the bacon that medical care.
Chip: Orange, I don't make any money if the doctor recommends castor oil, the doctor doesn't, the drug store doesn't appreciably, and for all practical purposes the patient has no expense.
While the little drug detail girl in the miniskirt does make a tempting presentation for restasis, it fails and castor oil doesn't. Now I don't know how money and greed got into this, as the preventative mentioned was fear of lawyers.
But why Rx things that only work from the chair to the parking lot when the cure has been around a long time, cost next to nothing, has no adverse effects, and actually work? Of course I admit that doctors must get a lot of pressure from patient's seeing direct to the public drug commercials and asking: "Doctor can I take this?" Doctors must hate this.
You may not recognise this, but I am trying to help you with this, if you are patient motivated.
orangezero: I'd prefer not to get too wrapped in the whole money/greed issue myself, sorry to go there. I'm curious why you think restasis doesn't work? I haven't checked in store (you've got me curious), do you tell patient's to get the stuff on the shelf you use for vomiting?
Chip: Orange,I have seen many, many patients who found that restasis didn't work or provided only momentary relief. Castor oil isn't for vomiting it's to cause things to pass through the bowel. And yes, the stuff on the drug store shelf is the same stuff. The stuff in the paint store is toxic.
In the fine print you will find that restasis provides only temporary relief, not a cure and it lowers one's immune capabilty to infection, castor oil does not.
Wouldn't you like your patient's to tell other patients that you were that wonderfull doctor that told them about this. Cured them of the problem and they didn't require and Rx and it cost next to nothing. Above all it worked.
I'm not sure how it works for you professionals but as a non professional and as a suggestion for which no fee is charged, one is not practicing medicine or optometry. Just being a helpful friend.
Postscript:
Sorry Chip, but it looks like the little dish in the mini-skirt won.
Allergan's RESTASIS Approved by the FDA; The First And Only Therapeutic Treatment To Increase Tear Production In Patients With Chronic Dry Eye Due To Ocular Inflammation
Final Score
Castor-oil (backed by the positive results) - 0
Restasis (backed by the drug companies) - 1
Debt Crisis 2011: All the ostensible nobility in the world notwithstanding, we have run out of other people's money to spend.
I think what he's trying to say, in a slightly awkward ergo unfamiliar way:
If a MCR claim has a 92105 submitted in conjunction with an ophthal. code but zero charge listed, MCR will automatically deduct 20% from the ophthal. code?
I think this may have been true in the past?
The harsh and real truth is that YES people ignore the health of their eyes everyday, there are far more people at McDonalds ignoring the health of their heart, or those at the liquor store right now ignoreing the health of their liver.
You have an obligation to check the health of a patients eye's, it is now through legislation a privledge and a burden. I do have an issue with a refraction being considered seperate from a comprehensive exam. Why? Refraction being inseperable from a medical exam has been the OD's battle cry for years as a reason why opticians cannot perform refractions yet if a patient presents with a cheif complaint of "Blurry Vision", you start with a comprehensive medical examination, then when they check out you offer them another examination, a refraction to determine if it's a refractive error.
If the care is gonna be "ala carte" then why shouldn't the patient have a choice?
The sole reason your profession doesn't feel comfortable offering just a refraction is for fear of litigation, so now the patient has to pay for additional testing beyond what could be necessary every visit to your office because he may want to update the Rx on his glasses or contacts. This is a disservice, IMO and a niche I think opticians can and should fill. If the procedures can be offered "ala carte" then the patient should have a choice who provides which components and shoud not be obligated to get all services at one office.
- Comprehensive and Refraction
- Comprehensive No Refraction
- NEVER just a Refraction
Personally I know many patients that will see an OMD for their health and then go to an OD for the refraction, but the OD has to redo everything all over again. :hammer:
On another health note according to the NEI at NIH between the ages of 40-49 only 5.3% of the population has Cataracts, AMD, and/or Glaucoma. If you add Diabetic Retinopathy to the mix your percentage goes up to 6.7% of the population.
Now look at the data for estimated Myopia and Hyperopia it totals to 39.5% of 40-49 year olds.
6.7% medical / 39.5% refractive - Given those numbers which test would you be more likely to have done first? Also keep in mind the patient has the right to refuse a dilation, I often do. So then what does a comprehensive exam include?
http://www.nei.nih.gov/eyedata/pbd_tables.asp
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Same in SC. Most insurances will screw you if you don't divide it up.
Actually REQUIRED to charge the patient for it. If you don't charge for it, you could be in trouble during an audit.
No. No. No. No. No.
Completely wrong. Many years ago, Medicare would deduct the refraction from the exam fee. At least 7 years ago, they determined it was optional. You may report it or not.
I can't tell you how refreshing it is to hear this from an OD. I self contract billing and I feel like I am always arguing this point. The refraction is a separate procedure. Whether or not a carrier we're contracted with pays it global or deems it patient resp is up to each contract. Sometimes they complicate matters for us more and require certain dx as primary, etc. etc. But if you agree to sign up with them, then that's part of the deal unfortunately. I also feel that a practice can lose money if they aren't billing for all procedures done. In general I always advise that: if you did it, then document it and bill it. If it's not documented, it didn't happen. (at least from a coding/billing point of view) Even if it is not covered or it's bundled, at least you have an internal account of procedure codes and how different payors are handling them, what your global w/o's are, etc.
I think some practices don't want to bill for the refraction because if it gets denied as not a covered benefit, then they have to collect it from the patient along with a copayment and for some reason some docs hate asking for their rightful copayments. But hey, it is what it is. I don't like paying for fillings and xrays on top of my copayment, but I have to if I want teeth! There's alot to discuss within this topic and I'm glad to have found this resource!
Always remember that 95% of patients and customers judge a doctor's worth and whether or not to go back to him on how well they see through thier glasses. Unless one needs medicine, or surgery it doesn't make a bit of difference to the patient if one is the greatest at medicine or surgery in the world. The patient is coming in for a refraction and a pair of glasses, patient is probably totally unimpressed with a "medical eye exam" no matter how thorough if nothing of significant medical importance is found.
And no I hope I am not encouraging doctors to invent something of "significant medical importance" to impress the patient.
However in defense of the above I did have very experienced and competent ophthalmologist tell me once: " Patient's used to come in when they were afraid something was wrong, and if you told them there was no cause for concern, they were happy.. Now patient's come in and if you don't give them some sort of eye drops (even if they are useless placebo type) they go to another doctor."
Strange how society is evolving isn't it?
Chip
Yes, some of the thought process out there is definitely scary.
Why does everyone continue to get so technical about this?
YES!!! In the doctor's Office a refraction is a separate code! But there are two ways of getting paid for it by Medicare.
1.) Medicare does not consider a refraction to be a separate procedure and you may include the charges in the cost of an exam! (If you don't believe me contact me via my website for further discussion www.rlrbillingsolutions.com/contact.html)
2.) If you are more comfortable documenting the procedure you may bill medicare for it separately on the claim, however it will not be paid and if you call in for an explanation they will tell you exactly what I just said in #1. So, when following example #2 your best bet is to charge the patient for this up front and report it on the claim as paid in cash. This will then count toward the patient's deductible!
Again, if anyone would like to talk to me about this in more detail, please contact me through my website http://optometricbilling.rlrbillings...ontact-us.html. I am a professional medical biller specializing in Optometric Billing and I would be more than happy to share with you any information that I have or just offer answers to some questions you may have.
I believe Doctors have a valid reason to be concerned about the rules and regs of their billing because the industry is constantly changing. Unfortunately things are not always presented as cut and dry. To further complicate things, there are the specific LCD's of all other payors they are in contract with. Then that is sometimes sub-categorized when routine benefits (and now sometimes medical vision) are carved out to yet another payor. And in the end, they must be coding/billing/charging the same for all or be concerned that they might violate Starks Law/Anti Kick-Back, etc. Unfortunately, I haven't seen any documentation regarding what you're explaining. I'd love to see the links, though. For Medicare specifically, our carrier's Ophthalmology/Optometry Billing Guide from April 2008 states "...Expenses for all refractive procedures,...are excluded from coverage." We bill with appropriate mod's to receive official adj to then be able to charge the pt or forward to the secondary. I don't see how we can't be technical when billing for this specialty.
barb
Barb,
You are absolutely correct! Doctors do and should have a valid reason to be concerned. However with medicare, the more concern you have the more confusing it is. Yes the billing guide does state it is included from coverage but what it doesn't tell you is that it is excluded from separate coverage because the refraction is considered "to be part of a routine eye exam". This means that you can adjust the cost of an exam when billing to include the refraction when filing a claim.
Ex:
Cash Patient:92004= $80.00
92015= $35.00
Medicare Claim: 92004= $115.00
(contact me at www.rlrbillingsolutions.com/contact.html for more info.)
I understand completely what you are explaining. We do this with some carriers that spell out specifically that the refraction is included in the eye or E/M code. Of course we then make sure that the payors that receive their claims with it split, have the fees adj accordingly also. My concern is that I have not seen any documentation supporting the statement that Medicare deems the refraction included in the office visit. Just that it's excluded. I'm not saying it isn't out there, just haven't seen anything like that and honestly none of the clients I have (that keep on top of these things) have mentioned that either. And these OD's are aware of the examples you have described. Any links for this CMS regulation you're talking about? I'd like to be able to research it.
Barb: I appreciate the kindness. People like you are the high priestesses of third party management, and your knowledge is like gold.
RLR: Are you saying that if our U&C ophthalmological code is X and our U&C refraction is Y, we can simply submit a ophthalmological code to MC as X + Y on a case-by-case basis?
Or, are you saying, in essence, that we can set our U&C ophthalmological code high enough to regularly include refraction, and just submit the the ophthalmolgical code and be content with the reimbursement for the exam only?
Thanks for your insight, RLR.
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