billing & coding
SOS on S Codes
Establish guidelines for your practice.

Intermediate and comprehensive eye examination codes, evaluation and management codes and consultation codes are all options for billing office visits. There is also a good deal of confusion, as well as potential misinformation, surrounding their use. Regardless of the patient's situation, insured or private-pay, it is unlawful to have separate fee schedules for the same services for different patient groups. Codes S0620 and S0621 for new and established patients, respectively, are defined as "routine eye examination including spectacle refraction." This differs from intermediate and comprehensive eye examinations as defined by Current Procedural Terminology (CPT), which does not include refraction. The refraction (CPT 92015) can then be billed as an additional procedure.

S-codes are a part of the Health Care Procedural Coding System (HCPCS) and do not fall under the CPT guidelines. Medicare and other federal health insurance companies do not recognize them. Currently, use of "S codes" for comprehensive or routine eye examinations is limited amongst the eyecare provider community.

S is for serious

Those who favor S-codes for routine eye exams feel they offer a competitive advantage or a legitimate way to provide a comprehensive eye exam (including refraction) at a reduced fee for private-pay patients who present without medical complaint or diagnosis.

While this may sound appealing if you have a high number of private-pay patients in your practice (probably not more than 10%), consider the possible ramifications. Essentially, you will provide the same services as with any comprehensive eye examination (CPT 92004 or 92014 with 92015 refraction), but you'll be charging less because the patient presents without insurance or complaint. In the end, this will only benefit the managed care/insurance companies.

Slippery slopes

Consider: What if a patient presents with no complaints, but you diagnose a corneal dystrophy or retinal degeneration, or macular edema in a patient with 20/20 visual acuity who is unaware they have diabetes mellitus. These medical diagnoses are not representative of the patient's chief complaint, so would be qualified as a secondary diagnoses. Why devalue the eye examination by billing for less just because the patient is private-pay?

The value of the comprehensive eye examination does not change, regardless of whether the patient presents for "routine care," with a refractive or medical complaint or without insurance. Charging a lesser fee for the same services is simply dishonest and unlawful. Before using the S-codes in your practice, consider all potential outcomes because there is considerable misinterpretation and confusion surrounding their use.

DR. MACK IS DIRECTOR OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.