The refraction test, also termed vision test, is an examination that tests an individual's ability to see an object at a specific distance. The test involves looking through a device to read letters or recognize symbols on a wall chart through lenses of differing strength which are contained within the device. This test is performed as part of a normal eye examination to determine whether an individual has normal vision. It is also used to determine the prescription for eyeglasses or contact lenses.

Avoid Denials by Billing Separately

Unfortunately, Medicare considers this a routine test and therefore does not approve it making it a non-covered service. Since Medicare doesn't cover it, many commercial insurance companies follow suit and also consider it a non-covered service.

Revenues accrued out of optometry billing of patients covered by medical insurance are more than those realized by billing the ones covered by vision insurance. The reason is quite simple, there are more patients covered by medical insurance than by vision insurance. Moreover, when it comes to reimbursements, the amount realized from medical insurance is always higher than what can be got from vision insurance. Whether it is medical or vision insurance, it is important to avoid denials, and one great way is to bill refraction separately.

Optometry Medical Billing Mistakes

There are 2 common mistakes that optometrists make in their optometric billing. Firstly optometrists tend to submit a refractive diagnosis code along with a 92000 eye exam procedure code. The reason is not difficult to understand – most of the insurance companies do not offer coverage for refractive care. However, it is not an offence to submit a 92000 code along with a refractive diagnosis code, and the optometrist is not liable to be charged with fraud.

While trying to bundle certain procedures non billable along with another billable procedure, it is considered as bundling, which is classified as an insurance fraud. Optometry billing services can be a tricky affair unless you know where to include refraction while submitting a claim to the medical carrier. It is better to look up the Local Coverage Determination for 92000 eye exam codes, which has an exhaustive list of tests that are approved. Most optometrists make the mistake of bundling refraction and eye exams together because ironically Medicaid billing permits inclusion of refraction with 92000 codes. Even the American Optometric Association (AOA) approves refraction along with an eye exam.

Why Refraction Cannot Be Billed Inclusive?

Medical carriers are opposed to including refraction in medical eye exams because they do not consider refraction necessary to keep eyes healthy. Never mind the fact that most pathology is found during visits in which refraction is performed.

Medical carriers are also opposed to including refraction in medical eye exams to control costs. If they allowed refractions to be bundled with exam codes, patients would always use their medical insurance for routine eye care instead of their vision insurance. Insurance companies would then have to pay us higher medical reimbursements. With the reimbursement for a medical 92004 code hovering around $120, it's easy to see why some doctors don't mind throwing in a free refraction if it means getting paid at a rate much higher than vision plans offer, which typically range from $40 to $80.

From a medical carrier's viewpoint, the practitioner who includes refraction at no charge essentially baits patients in for a routine eye exam and then bills the medical carrier for the costs. Therefore, medical carriers mandate a separate charge for refraction to prevent practitioners from billing medical insurance for a non-covered service. This same principle is behind the mandatory collection of co-pays, which deter patients from abusing health care benefits. Eye care professionals who fail to charge patients for refraction are as guilty as practitioners who routinely waive co-pays to attract higher patient volumes.


It is an ongoing battle between the medical practitioners & optometrists included and the third-party payers. This is because the insurance companies always want to wangle out from making payments, or at least end up paying less to practitioners. The federal government realized the gravity of the situation a decade ago and brought in an objective system of valuation for services rendered. This system is known as the Resource Based Relative Value System, which clearly defines every single professional service. The LCD was derived from this system after a few refinements.

With a bit of confusion still in the air, the rules and definitions spelled out for refraction billing, optometric billing for eye exams, and medical coding and billing in general, are set to witness more modifications, which are inevitable. Meanwhile, it makes sense to stick to the current rules in eye exam billing. In case refraction is omitted while billing, it is bound to be detected in subsequent audits. It is better to avoid penalties, which could be far greater than the reimbursement itself.

Published By - Medical Billers and Coders
Published Date - Dec-14-2017 Back

Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes?



Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes ?





Would You like to Increase Your Collections?