The chief complaint sets the stage for the rest of the exam

According to CMS, the chief complaint is “…a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s words.”¹ It is the answer to the question, “Why are you here?” From a clinical perspective, it helps set the stage for the rest of the eye exam. From a reimbursement perspective, it is an important part of the determination of who is responsible for the claim for reimbursement: medical insurance, vision insurance, or the patient.

The chief complaint can be obtained by a physician or any appropriately trained member of the staff. In the lane, it is an easy matter to start with an open-ended question such as, “How can we help you today?” You don’t have to record every word the patient says; it is sufficient to summarize the salient points.

DETERMINING COVERAGE

Coverage depends on the purpose of the eye examination, as well as the ultimate diagnosis of the patient’s condition. If the beneficiary has a complaint or symptoms of eye disease or injury, the examination is covered even though only eyeglasses were prescribed. An example is mild cataracts requiring only a small increase in minus lenses.

Within the Medicare program, as well as many health plans of other third-party payers, routine physical checkups are excluded from coverage.^2,3 They are defined as, “Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury…” except for certain statutorily covered screening exams (eg, glaucoma screening).⁴ Additionally, the Medicare benefits manual states, “Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered.”⁵

Eye exams for eyeglasses or contact lenses produce a final diagnosis of refractive error like myopia, hyperopia, or astigmatism. So, a patient who says, “My eyeglasses aren’t satisfactory, and I want to get new ones” falls within this Medicare exclusion. A patient who says, “I just want to check the health of my eyes; it’s been a long time since I had an eye exam” likewise falls within this exclusion from Medicare coverage. An ICD-10 code in the series Z01.0 (Encounter for examination of eyes and vision) applies. Importantly, an incidental finding of disease during a routine physical checkup does not render it a covered Medicare service when the chief complaint indicates that is not the purpose of the eye exam.

For both of these situations, a vision plan would cover the eye exam instead. Explaining coverage to patients who have both medical and vision coverage can be challenging because they don’t necessarily understand how a chief complaint can determine which plan will pay for the visit. Due to differences between plan requirements for beneficiary copayments and deductibles, these beneficiaries often want to use their insurance like currency without realizing the inherent coverage limitations. Before a claim is filed, billing personnel must determine which plan applies, and the chief complaint is the principal determinant for making that decision. Note that the same eye exam cannot be billed twice – once to the medical plan and then again to the vision plan.

WHEN THERE ARE TWO COMPLAINTS

Some patients give two complaints simultaneously: one related to disease or injury, and another that falls within the Medicare exclusion that states, “Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for the performance of the refraction, are excluded from coverage.”⁵

According to CMS instructions to Medicare Administrative Contractors,⁶ the complaint related to disease or injury is separate and distinct from the indication for a refraction, and the denial of the refraction has no effect on the payment for the covered eye exam on the same day. Consider the case of a diabetic patient with uncontrolled diabetes who asks for new eyeglasses. The request for new eyeglasses sounds routine and refractive, but uncontrolled diabetes is not (and probably explains the change in refractive error). In this case, diabetes mellitus is the diagnosis on the office visit, and the refractive error is the diagnosis for the non-covered refraction.

DELVING DEEPER

Most patients have little understanding or appreciation for the arcane and often abstruse rules of payers. It is fair to say patients need our help understanding their health insurance coverages and how coverage depends on the chief complaint.

Obtaining a chief complaint requires more than a vague answer to the question, “Why are you here?” Take a few minutes and pay attention to the patient. They need a chance to remember and describe their symptoms. If the patient remarks, “Here to have my vision checked,” and you leave it at that, you miss an opportunity to delve a little deeper and discover other visual symptoms that could differentiate a routine eye exam from a medical exam. Incidentally, you might also miss out on important medical information. OM

REFERENCES

1. Center for Medicare and Medicaid Services. HCFA 1997 Documentation Guidelines for Evaluation and Management Services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf . Accessed Jan. 21, 2022
2. GovInfo. 42 CFR 411.15 Particular services excluded from coverage. https://www.govinfo.gov/content/pkg/CFR-1999-title42-vol2/pdf/CFR-1999-title42-vol2-part411.pdf . Accessed Jan. 21, 2022
3. Social Security Administration. Social Security Act 1862(a)(7). https://www.ssa.gov/OP_Home/ssact/title18/1862.htm . Accessed Jan. 21, 2022
4. Social Security Administration. Social Security Act 1861(s)(2)(U). https://www.ssa.gov/OP_Home/ssact/title18/1861.htm . Accessed Jan. 21, 2022
5. Center for Medicare and Medicaid Services. Medicare Benefits Policy Manual Chapter 16, §90. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c16.pdf . Accessed Jan. 21, 2022
6. Center for Medicare and Medicaid Services. Transmittal 1690, January 5, 2001. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1690B3.pdf . Accessed Jan. 21, 2022

BRANDY H. SPERRY is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext. 238.