coding q & a
Medical Vs. Vision Insurance
Confusion often rules about which insurance to bill for a service.

By Suzanne Corcoran, C.O.E.

Q: Are "routine" and "annual" exams covered?

By law, Medicare doesn't pay for routine vision exams. Medicare beneficiaries may choose to have an "annual exam," but they are responsible for payment. Some beneficiaries may have vision insurance that covers the exam. Private major medical insurance plans sometimes include a routine eyecare benefit. Check your individual plans.

Q: If a patient has both medical and vision insurance, which is primary?

This depends on the reason for the visit, from the patient's perspective. Bill exams for medical care, evaluation of a complaint or to follow an existing medical condition to the medical plan. Alternately, bill examinations that check vision, screen for disease, or update eyeglasses or contact lenses to the patient or to the patient's vision plan.

Q: When a patient presents for a routine vision exam and you find a pathology, can you bill the medical plan?

No, the chief complaint should relate to the primary diagnosis and determine coverage. In this case, the chart may read, "here for routine eye exam and new glasses" with a corresponding diagnosis of refractive error, including myopia, astigmatism or presbyopia. Address the incidental finding of pathology on a return visit. Bill the subsequent exams to monitor or treat the pathology to Medicare or to the major medical plan.

In the event of an urgent or emergent medical condition, consider the medical plan as primary and the vision plan as out of the picture. Carefully explain the circumstances and gravity of the situation to the patient to avoid later recriminations or questions.

Q: Is it ever possible to bill both medical and vision insurance on the same date?

It may be, depending on the patient's vision plan. Some plans will cover a refraction even when the medical plan covers the visit. If the vision plan allows it, submit the claim with the appropriate medical diagnosis associated with the visit and a refractive diagnosis mated to the refraction.

Q: What happened to the local codes that described a routine eye exam?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes rules for "standard code sets," which eliminated payers' ability to create and use their own codes to describe services provided. Some payers replaced their routine eye exam codes with HCPCS codes.

HCPCS codes S0620 (routine ophthalmological examination including refraction; new patient) and S0621 (...; established patient) specifically describe routine eye exams, including refraction. These codes are appropriate for healthy patients who come in for a regular check up and for new eyeglasses or contact lenses. Medicare doesn't accept these codes, although other plans may.

Q: How can we reduce confusion with patients on this subject?

Start by determining coverage on the phone during the initial call for the appointment. When the patient arrives for the appointment, confirm the reason for the visit. Some practices use stamps or stickers in the chart to alert the doctor to the reason for the visit and the limitations of coverage.

Keep in mind that patients frequently do not understand their insurance coverage and may be disconcerted to find that it doesn't pay for some service they want. 

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.