software solutions

The Same Tool ... Different Answers
Two O.D.s analyze vision plans with the help of EyeCOR software.
BY MARK BOTWIN, O.D., & D.C. DEAN, O. D.

As optometric physicians transition from "vision" providers to "medical" providers, a fundamental practice management question arises: Should practices accept vision care plans? Two optometrists, Drs. Mark Botwin and D.C. Dean, present their first-person perspectives below.

DR. BOTWIN: Keep the plans

Our practice participates in many vision plans as well as medical plans because vision plans bring patients into our practice who we would otherwise not see. Plans also bring patients back, which is a benefit for the patient and our practice.

But I don't rely solely on vision plans. When I diagnose a medical problem during a "routine" visit, I reschedule the patient for a medical visit.

For example, if I notice suspicious nerve heads, elevated IOP, or other glaucoma suspicions during the routine visit, I'll reschedule the patient for a glaucoma work-up. This first visit is billed 92004 (or 92014) along with 92015 to the vision plan. Visual fields, pachymetry, serial tonometry, fundus photos, and extended ophthalmoscopy are a few of the "Allowed Reimbursable" diagnostic tests that may be performed.

Fundus photos and laser imaging cannot be done during the same visit, so the typical glaucoma suspect work-up translates into three visits.

For patients who present with a medical complaint, the challenge is to determine the appropriate testing and then to code and bill correctly. While complex, knowing what diagnosis links with which billable procedures translates into correct billing, which reduces the time spent rebilling and results in maximum reimbursement.

I use EyeCOR by Nteon software program to assist me in determining what procedures can be performed for a specific diagnosis. I also use the Wills Eye Hospital manual to help determine the standards of care.

In the example above, I generally bill a 99212 or 92012 for the "medical" visits in addition to the tests that we perform. Be aware that the actual test accounts for 60% of the billable fee. The remainder is attributed to the Allowed Reimbursable procedures (with Interpretation and Report of your findings). The EyeCOR program generates Interpretation and Report forms.

Optometric physicians should drop plans with low reimbursement. But they should also become panel providers to medical plans. To provide the best care, take advantage of tax laws and purchase instrumentation and tools that allow you to practice and bill at your highest levels.

DR. DEAN: Drop the Plans

Many years ago, private practitioners rallied around the flood of vision plans as a defense against the onslaught of commercial optometry. Then the unthinkable happened.

A few radical optometrists billed medical insurance to cover eye exam services. Granted, the rules for billing seemed daunting to a newcomer. But these optometrists were doing it. And the fees were in line with those of ophthalmologists.

In New Mexico, which comes in lower than the national average, Medicare reimbursements for a comprehensive eye exam are $187.35, or $122.18 (92004 Comprehensive Ophth. Exam - New Patient) plus $65.17 (92015 Determination of Refractive State). Our best vision plan pays $90 — our worst pays $32. Wal-Mart advertises $29.95 exams in the local newspapers.

It's time we rise past our status as "vision providers." We are under the same legal responsibility to diagnose every possible pathologic condition of the eye as an ophthalmologist.

We've been led to believe that patients walk through our doors only because of vision plans. Yet a growing number of our colleagues only participate on the medical provider lists. (You can't do both. Vision plan contracts don't allow you to bill medical insurance for an eye exam.)

Medical Billing for Dummies

You have to apply to medical insurers and HMOs in order to get on the provider panels. Every state optometric organization should initiate and/or support their own "Any Willing Provider" or "Eye Care Access" bill to redress access issues. Call the legal department at AOA for assistance in drafting and promoting your bill.

Once on the panels, you'll need new forms for every step of the medical billing process. You'll need new reference tools. EyeCor software contains all the requirements for both 92000 eye exams and 99000 E/M codes. I can't remember the last time I picked up a CPT or ICD-9 code book.

EyeCor shows all the Allowed Reimbursable Procedures for a specific diagnosis. This encourages our office to perform the proper tests so we provide a higher level of care. Additionally, this feature has helped our office successfully bill tens of thousands of dollars in medical fees just in the last year.

Difficult but well worth it

Learning to run a fully compliant 92004 billing program is difficult. I strongly recommend taking the entire staff to billing presentations as your staff will be responsible for 80% of the success of your medical program. Optometric consultants can jump start your program. The training takes a day, but it saves lots of money in mistakes.

You already have all the equipment you need. Now it's time to discover one of the most lucrative and risk free procedures available to any eye care provider.