Optometric Billing

[mhavlik]

I currently work at a small independent optometry clinic in MN. In MN, most medical insurances cover a routine eye exam (without any deductible, co-insurance or copay), but with the upcoming ACA changes, adult routine eye exams will no longer be covered. I was wondering what advice/help you can give me for transitioning our clinic from routine billing to medical billing. The biggest challenge will be helping our patients understand that we can still see them this next year, even though their insurance doesn't cover a routine exam.

thanks in advance for your advice!

[becc971]

some of the changes that have been made by insurances here in my state have been that none of the "opia's" are acceptable anymore (myopia, hyperopia etc) ... so not using those as diagnosis is a start, and also the V72.0 routine vision exam.

i BELIEVE but am not POSITIVE that routine eyes can still be covered under any individual insurance plans even with the ACA coming into affect. but it is up to the insurance companies. even now we have certain BCBS plans that will, and ones that will never cover routine vision. We have a woman in our office who calls, verifies whether they have routine or medical coverage, and writes a note on their fee tickets so the techs know whether or not they need to find a medical diagnosis. This is a full time job in a 5 doctor practice but if you have fewer it could easily be added onto someone's workload :)

hope this was at least kind of helpful :)

[jpways]

The primary key to medical billing in an optometric office is you have to have billable diagnosis codes, things like cataracts, AMD, diabetes, glaucoma, dry eye syndrome, are among things we bill then you have to determine the type and level of code you are billing the common medical exam codes (CPT) are 99201, 99202, 99203, 99204, 99211, 99212, 99213, 99214, 92002, 92004, 92012, and 92014 there are some rules for which code should be billed for the exam (there is also 99205, 99215, 99241, 99242, 99243, 99244, and 99245 but these codes are used infrequently if at all in optometry and the 9924x codes are not billable through all insurances).

Then there are of course the other tests that can be billed based on whether you have the available equipment and medical necessity: Fundus Photo, OCT, gonioscopy, pachymetry, visual field testing (perimetry) (again not a complete list)

If the training for the Doctor(s) in your office was similar to the training for the Doctor in the office I work for, they should already be aware of most if not all of the medical codes they should be able to bill during their exam. Most of the Optometric CE that our office's Doctor attends includes codes that can be billed as do many of the article in the Optometric journals (Optometric Management and Review of Optometry are my 2 favorites to look through for coding help). If you have not already sit down with your the Doctor(s) in your office and try to figure out what can be billed medically.


And always check the plan rules (or call) to make sure that you can't bill routine, but in many cases you will get reimbursed more for medical exams vs. routine exams.

If there's any other questions that you come up with you can't find an answer for on another Optiboard thread post it here or PM me.

[mhavlik]

I'm sorry I didn't make my questions more clear in my original post. I was wondering what your practice currently does to help patients understand the difference between why you bill their insurance as a medical office visit rather than a routine eye exam, or how you've transitioned your practice from billing routine exams to billing medical exams. Was there a lot of re-learning on the part of the doctor to perform medical exams versus routine? Can you still bill for the refraction, if you are a medical billing clinic? I've heard that you can get reimbursed more for medical exams versus routine exams, but I wasn't sure how all the logistics worked if the patient has VSP along with their medical insurance, or if you see a patient for a medical reason (glaucoma) but they also want a glasses prescription.

[jpways]

I'll start with the easy question yes you can still and should bill refraction separate from the exam, if it is being performed, some insurances will pay it, some don't (like Medicare)
As to how to explain it, the simplest explanation I have, There is a condition that Doctor is monitoring so we are billing today's exam to your medical insurance. How specific I am on to what the condition depends on where I am at the time of the explanation.

[mhavlik]

thanks!!

[fjpod]

tough questions...Firstly, routine adult eye exams will not necessarily be discontinued because of the ACA. Secondly, you can bang your head and your patients head against a brick wall trying to explain the difference in optical vs medical insurance and they still won't get it. It gets really dicey when someone comes in and says, I just want to get a new pair of glasses but I am diabetic and my doctor says I need a dilated exam...and oh, I can't see out of my left eye, maybe it's because of all the laser surgery I've had. So what is that? A medical exam or a routine visit.

You have to weigh the reason someone came in to you in the first place, with medical history they may relate to you after asking probing questions, and whether you uncover active pathology during a "regular" exam.

There is no limit to ocular conditions that are billable under medical insurance, but of course your patient must have one of them, or at least come in complaining of one. Coming in to order new glasses doesn't count.

[LENNY]

tough questions...Firstly, routine adult eye exams will not necessarily be discontinued because of the ACA. Secondly, you can bang your head and your patients head against a brick wall trying to explain the difference in optical vs medical insurance and they still won't get it. It gets really dicey when someone comes in and says, I just want to get a new pair of glasses but I am diabetic and my doctor says I need a dilated exam...and oh, I can't see out of my left eye, maybe it's because of all the laser surgery I've had. So what is that? A medical exam or a routine visit.

You have to weigh the reason someone came in to you in the first place, with medical history they may relate to you after asking probing questions, and whether you uncover active pathology during a "regular" exam.

There is no limit to ocular conditions that are billable under medical insurance, but of course your patient must have one of them, or at least come in complaining of one. Coming in to order new glasses doesn't count.

What about if they complain that the medication ran out from their glasses?
Is it medical or routine? :)

[braheem24]

What about if they complain that the medication ran out from their glasses?
Is it medical or routine? :)

It's medical, 1 inch behind the eye.