Medicare beneficiaries are often confused that refraction is an out-of-pocket expense. Eye care providers (ECP) aren’t thrilled explaining that it is considered an incidental part of an eye exam vs. a diagnostic test. So, what’s the story?
Chapter 1: Documentation
A prescription is evidence of a completed refraction. Under Medicare’s Durable Medical Equipment Regional Carrier regulations, the prescription must have the original ink signature/date of the OD.
A prescription supports the charge for a refraction.
Chapter 2: Legislation/regulation
The Federal Trade Commission (FTC) Prescription Release Rule “requires eye doctors to give patients their eyeglass prescription at no extra cost immediately after an exam that includes a refraction. The eye doctor may withhold the eyeglass prescription until the patient has paid for his/her eye exam, but only if the eye doctor requires immediate payment whether or not a prescription is needed.”
See the FTC’s final updates to the Eyeglass Rule at bit.ly/FTCEyeglassRuleUpdate.
Chapter 3: The -GY modifier
The –GY modifier means “not covered by statute,” and the prac- tice is not obliged to give the patient an Advance Beneficiary Notice (ABN). If the modifier is not used, Medicare carriers have computer edits to reject claims for 92015, although it is more precise to include the modifier rather than omit it.
For good patient relations, make Medicare beneficiaries aware (e.g., incorporating a clause in your patient registration document[s]) of their financial responsibility for refractions.
Chapter 4: S-codes
Healthcare Common Procedure Coding System (HCPCS) contains Private Payer Codes that don’t apply to Medicare. Of particular interest are S0620 and S0621.
S0620 – Routine ophthal-mological examination, including refraction; new patient
S0621 - Routine ophthalmological examination, including refraction; established patient
Since the inception of HIPAA’s uniform standards for code sets, these codes have become more widely accepted for filing claims, particularly with vision plans, as well as for distinguishing “routine exams” from treating disease or abnormalities. This is especially relevant in cases in which you want to make a distinction in the charge for the exam based on its purpose, as well as a condition’s gravity. ECPs should check with their policies to see whether this code is accepted. They can also use these codes for accounting purposes when the patient doesn’t have vision insurance for a routine eye exam and is responsible for payment.
Chapter 5: Medicare regulations
ECPs have the sole authority to establish the value of a refraction. If desired, the refraction can be free without fear that the Medicare reimbursement for the associated eye exam will be affected. However, if it is free, it must be free for all. I am not suggesting it should be free, as it is a valuable part of the visit. However, no charge means no charge for all patients.
Medicare Advantage Plans and other third-party payers may consider the refraction part of the exam or cover it under the patient’s plan, so ECPs and staff should not assume the refraction is not covered. ECPs should follow prior authorization processes for refractions for patients who have commercial plans and follow the predetermination process for patients with Medicare Part C.
The end
To review: FDA regulations and the Fairness to Contact Lens Consumer Act require a prescription copy to the patient. An ABN isn’t required for Medicare beneficiaries for a refraction, but let them know their financial responsibility. Lastly, Medicare won’t intrude in this area of your practice as long as you are consistent with all patients, as it is a non-covered service.
