Avoid Denials by Separately Billing Refraction

Revenues accrued out of optometric 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.

There are two 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. Moreover, submitting a367.1 myopia code along with a 92004 code invites definite claim denial by the medical carrier. 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 bundling, which is classified as insurance fraud. Optometric billing 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 (LCD) 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 the inclusion of refraction with 92000 codes. Even the American Optometric Association (AOA) approves refraction along with an eye exam.

So, why is it that refraction cannot be bundled with a 92000 eye exam code? O.Ds should realize that medical carriers do not consider refraction very essential for keeping the eyes healthy. This may be because they want to keep the costs down. However, instead of arguing about who is the best judge (certainly not the medical carriers) on medical issues, it is better to accept the fact that optometric billing does not approve refraction as part of an eye exam – period. Medical carriers on their part advocate separate charges for refraction, which is not covered under Medicare billing.

It is an ongoing tussle 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 prevailing in 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.