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When Is Routine Eyecare Not Routine?
Many services we provide — including care for contact lens patients — may be anything but routine. Here's how to differentiate medical from nonmedical when coding for reimbursement.
By Charles B. Brownlow, O.D., F.A.A.O.

For decades, eyecare professionals, especially O.D.s, have wrestled with the perception that some of the services we provide are "routine," while others are considered medical.

To compound the confusion, descriptions of these so-called routine and medical services often look the same in a patient's medical record. Yet, due to internal and external influences — not the least of which is the patient's history — coding and billing for these services can differ significantly.

In this article, I'll discuss the most common Current Procedural Terminology codes that classify these services and the criteria you should use to differentiate between them for accurate coding and billing.

Anything but routine 

It has long been my contention that O.D.s do not perform routine examinations. Every exam takes into account the overall health of a patient's eyes, including the surrounding tissues and
structures, the general well-being of the individual, and any ocular or systemic medications he or she may be using.

So the term "routine" should be struck from the vernacular of O.D.s and other eyecare professionals, and replaced with a more accurate description of the services we provide.

Patient visits should be characterized as either:

• Those for which there is a clear medical reason or chief complaint, or
• Those for which there is no clear medical reason or chief complaint.

The "Documentation Guidelines for the Evaluation and Management Services," developed in 1997 by Medicare and the American Medical Association (AMA), refer to only a discrete set of CPT codes: the 99000 series. For O.D.s, these usually include office visits (99201-99205 and 99211-99215) and to a lesser degree, consultations, hospital and nursing home visits and home visits.

Interestingly, neither the definitions found in CPT nor the documentation guidelines mention "routine" services, so we can assume the codes are intended to identify patient visits with a "medical chief complaint" or a "medical reason for the visit."

The other set of codes we use to represent patient visits (those with a medical reason and those without) are in the 92000 (ophthalmology) series: 92002, 92012, 92004 and 92014. The CPT definitions for these services do not mention "routine" services either. These codes are designed to report medical services, which, in my opinion, should be defined as services for which there is a clear, medical chief complaint or reason for the visit.

CPT codes must = CPT definitions

Occasionally, the AMA has had to remind providers and payers that the CPT codes they use for services performed must correspond directly to CPT definitions. In other words, no CPT code should be used to identify a service that does not match the CPT definition for that service. If one or more elements of the definition are missing, a different code must be chosen. Similarly, if at least one element of the documentation guidelines is not present in the medical record, a different code must be used.

In another example, if a healthcare plan pays for services that are for treatment and management of medical conditions, no visit or other services should be billed to that payer unless there is a medical reason or chief complaint associated with the visit. In addition, when a patient reports to your office without a complaint, the visit should be billed to the vision plan or the patient, even if medical conditions are discovered during the visit. Once you've made a medical diagnosis, subsequent visits and related services should be billed to the medical insurance carrier.

Medical services explained

Eyecare professionals and payers continue to be confused about the issues surrounding medical and nonmedical services even though they've been hotly debated. The Centers for Medicare and Medicaid Services (CMS) explains the difference between the two types of services for its carriers in the following the statement:

The coverage of services rendered by an ophthalmologist (or optometrist) is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to an ophthalmologist (or optometrist) with complaints or symptoms of an eye disease or injury, the ophthalmologist's or optometrist's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist or optometrist for an eye examination with no specific complaint, the expenses for the examination are not covered, even though as a result of such examination the doctor discovered a pathological condition. (It continues ...) In the absence of evidence to the contrary, the carrier may assume that an eye examination performed by an ophthalmologist (or optometrist) on the basis of a complaint by the beneficiary or symptoms of eye disease was not for the purpose of prescribing, fitting or changing eyeglasses.

Defining the visit

Because our services depend on the purpose of the examination and not on a patient's diagnosis, we should interview patients at the beginning and throughout the visit, determine why they're in the office, and customize case histories and examinations to match their needs. In each case, the doctor should record the related diagnoses and management options resulting from the patient's history and examination. Once the diagnoses and options are explained to the patient, he or she should be released.

Doctors should follow each of these steps for all patients, regardless of the patient's insurance coverage or lack thereof.

Only after the visit should you and your staff consider the patient's insurance and determine whether the claim should go to the vision plan (if the chief complaint/reason for the visit was nonmedical), or to the major-medical plan (if the chief complaint/reason for the visit was medical).

What about CL patients?

When it comes to contact lens wearers, determining whether a visit is medical or nonmedical poses another dilemma. Contact lens wearers occasionally need a foreign body removed from a cornea or lid. They may develop other corneal conditions related or unrelated to their contact lenses, including but not limited to dry eye, glaucoma, blepharitis or macular degeneration.

It has been common practice to default to the routine side of billing and submitting claims to payers. However, given Medicare's criteria for assessing medical vs. nonmedical services, the contact lens patient should be treated in the same manner as other patients, with the same rules applied, for determining patient care and billing procedures for each visit. So always take these key steps when contact lens patients come into your office:

• Interview patients carefully at the beginning of the visit and throughout to determine their needs. In short, identify each patient's "chief complaint/reason for the visit."

• Proceed with details of the case history and physical exam, customized in order to discover the underlying cause(s) for the "chief complaint/reason for the visit."

• Record any diagnoses and management options that result from the examination.

• Submit the bill to the patient or to the patient's vision plan if the "chief complaint/reason for the visit" is nonmedical.

• Bill the patient's medical insurance plan if the chief complaint/reason for the visit is medical in nature.

What's more, when patients report "chief complaints/reasons for the visit" that are medical, even though all their previous visits were nonmedical, you should continue to consider them as you had previously: as individuals in need of eyecare customized to their needs.

CLs for therapeutic use

As you know, contact lenses are occasionally used therapeutically to manage medical conditions. When this occurs, the visit and any appurtenant services should be considered medical. The visit may be related to dry eye, keratoconus, keratitis or another serious problem. In these situations, the patient's major medical insurance probably will cover the visits and services provided because of the "chief complaint/reason for the visit" classification — even if the patient's policy specifically
states it will not cover contact lenses or contact lens-
related care.

One often-misunderstood area of care — specifically as it relates to coding and reimbursement — is contact lens fitting for keratoconus patients. For most keratoconus patients, contact lenses are the only effective mode of care. For others, they're an integral part of a broader regimen of care.

Thus, even payers that exclude all contact lenses from coverage often cover visits and tests for keratoconus patients. Some health plans may exclude patient care related to keratoconus, including lenses, visits and procedures, which then become the patient's responsibility.

With other corneal and anterior segment conditions, such as eye infections, dry eye, keratitis and recurrent corneal erosion, the insurance carrier may not pay for the contact lenses themselves or any charges for fitting and management, although it would pay for the visits and diagnostic tests involved in the identification and management of the medical condition.

Reevaluating your practice

It goes without saying that the responsibility for following proper recordkeeping procedures as well as coding and billing protocols rests with the providers. This presents an important opportunity for you and your staff to provide optimal care for all types of patients and get paid appropriately. To accomplish this, you may want to reevaluate your internal coding and billing procedures to ensure your office is basing its decisions on the rules and not on habit or unwritten interoffice protocol.

Understanding the differences between medical and nonmedical services enables you and your staff to begin patient visits with open minds — not with preconceived notions about whether the patient's vision or major medical insurance plan will pay for your services. Once you and your staff members understand the rules and adopt clear protocols, everyone will be able to return to what they enjoy most and do best: provide excellent eyecare for patients.

The articles that follow will discuss in more detail how contact lenses, particularly silicone hydrogels, can be used to address certain patient complaints — and how these visits may qualify for reimbursement through vision and major medical plans.