Billing for Routine and Medical Eye Exams

Eye exams are one of those issues in optometry billing that can cause confusion. How to bill the exam as a routine exam or medical exam? Is there a difference? Clearing the confusion and understanding the basics is essential for the optometry billing department in order to avoid a delay in the claim processing. Many eye exams could fall under both vision and medical insurance, it is essential that these procedures must be coded properly to ensure proper payment. In this article, we discussed different elements involved while billing for routine and medical eye exams along with suitable clinical scenarios.

Medical Eye Exam

Seeing the ophthalmologist or an eye doctor can mean that a patient is having difficulty with his vision. This would typically lead to a routine exam and be billed to the vision insurance company. Seeing the same doctor for conjunctivitis or any other medical issue that pertains to the eyes would be considered for medical insurance. Of course, there is always the area in the middle that can shake the balance of whether or not the claim should be a vision or medical claim. In these instances, the chief complaint and medical history will play a role in which insurance is billed.

Above we discussed a basic clinical scenario, but most of the times things are not as easy as it looks in optometry billing. Let’s consider another example, a patient who came into your office for a routine eye exam or claim difficulty with his vision and have no other complaints. Upon completion of the exam, however, you find that he has medical issues, such as glaucoma or cataracts. If you ask the patient to come back and see you for a follow-up, whether a few weeks or a few months from now, the issue has now turned medical. The initial appointment to determine the level of difficulty that the patient was having with his vision still pertains to vision insurance, but as soon as the appointments are made and focused on a medical issue, medical insurance becomes responsible.

Routine vs. Medical Eye Exam

It is important to understand the difference between medical and routine exams to ensure you receive full reimbursement for your services. Distinguishing the difference between the two exams begins with knowing there are more similarities than differences. As discussed earlier, the chief complaint and diagnosis drive the exam. Therefore, if the primary diagnosis is medical and addresses the chief complaint, then it will most likely be billed as a medical exam. That said, don’t assume that every patient complaining of blurry vision has a refractive issue.

Often, a blurry vision has an underlying medical condition resulting in a medical ocular exam being performed instead of a routine exam being submitted to a vision plan. The case history performed on a new patient should not vary for a medical exam versus a routine exam since it is performed before you see the patient and the type of eye exam has not been established yet. The elements of the exam are similar between medical and routine exams with one major difference.

When performing a medical exam, you must choose the exam elements necessary to diagnose and treat the patient and perform only those tests. Many doctors will perform the same exam elements as part of a routine eye exam on every patient, which is not acceptable for a medical ocular exam because it may incorrectly raise the level of exam being coded for visit. The decision-making process is also different for a medical exam versus a routine exam since a routine exam requires little or no medical decision-making and a medical exam typically includes either low or moderate medical decision-making. Medical decision-making may be broken down into 4 levels: Straight-forward; Low complexity; Moderate complexity; High complexity.


To clear the confusion while billing for routine and medical eye exams, just focus on two levels: the low complexity of follow-up visits and moderate complexity for the exam involving a new problem presentation. In this manner, it is quick and easy to establish the level of decision-making, but keep in mind that occasionally you may see a patient who presents with three or more new problems. In that case, high complexity decision-making would be appropriate.

Understanding the differences between vision and medical insurance can be a tough task for any billing department. Whether handle optometry billing and coding all by yourself or employ in-house staff, extra care needs to be taken to determine which insurance is responsible. If your claims are getting denied due to confusion over deciding on routine or medical exams, we can assist you in optometry medical billing and coding. MedicalBillersandCoders (MBC) have a full understanding of which codes are considered medical and which are vision-related. Our billing and coding experts have been handling optometric billing functions for a long time now and it has become second nature for them to understand which insurance company is responsible for the various eye exam-related charges to make it easy for optometrists to stay efficient and profitable. For more information on our optometry medical billing and coding services, please contact us at 888-357-3226

Published By - Medical Billers and Coders
Published Date - Oct-06-2021 Back

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