Few codes are as widely used, yet frequently as misunderstood as CPT 92015 (refraction)—the theme of this month’s issue. Here, I discuss how to properly bill 92015, common pitfalls, and best practices.

Proper Billing

An optometrist can and should bill 92015 when:

• A refraction is performed as part of a vision exam to determine a new prescription or assess visual acuity changes.
• A medical eye exam (eg, for diabetes or glaucoma) includes a refraction for vision complaints or lens change evaluation.
• The patient requests a new glasses prescription.
• A refractive endpoint is needed postoperatively (eg, cataract follow-up) and vision plans or global surgery packages do not include it.

Common Pitfalls 

The common pitfalls associated with billing 92015 are:

• Failure to bill the patient when their insurance does not pay for refraction. If the refraction was performed, it must be billed whether it is covered by insurance or the patient pays.
• Billing vision plans when refraction is performed during a visit for medical complaints unless explicitly permitted by the plan.
• Billing 92015 to Medicare or medical plans expecting reimbursement. Most medical insurance payors, including Medicare, consider refraction a non-covered service because it is not deemed medically necessary.
• Assuming the electronic health record auto separates 92015 when it is actually erroneously bundles it with the exam code. 

Best Practices

Some best practices for 92015 are:

• Knowledge of the medical and vision plans. Vision plans typically include refraction as part of the covered eye exam benefit, though it may be carved out in certain plans. Medical insurance may deny 92015, but the optometrist can bill the patient directly. Medicare allows patient billing if the patient was informed in advance. (This is where the advanced beneficiary notice is crucial.)
• Clear patient communication. This entails training staff to explain that the refraction is often a separate fee. An example script for your front desk: "Today’s exam is being billed to your medical insurance because of [your eye condition/medical concern/follow-up]. If the doctor checks your glasses prescription or measures how clearly you see, that isn’t covered by medical insurance, including Medicare, which will cost ___ and can be paid at checkout. Let us know if you’d like us to skip that part of the exam today."
• Proper documentation. The refraction must be noted as manual or automated, the result (as in manifest refraction), and the reason it was performed, which should be covered in chief complaint and in the plan of counseling of the refraction.
• Proper modifier use. Some cases require a modifier. Postoperative or bundled postoperative services are examples of such cases. The GY modifier may be used to indicate a statutorily excluded service when billing Medicare.

Managing the Challenge 

By properly billing, avoiding common pitfalls, and implementing the best practices illustrated, optometrists ensure compliance, reduce claim denials, and preserve their clinic’s revenue integrity. In a time when margins are thin and audits are rising, understanding how to ethically and efficiently charge for refraction is essential to running a successful optometric practice. OM

Tonya M. Reynoldson, OD, MBA, is a senior eye care director for AEG Vision. She currently supports more than 100 ODs with clinical needs, such as billing and coding questions, electronic health record training, continuing education needs, and clinical staff training to create the best patient outcomes. She previously owned 2 private practices for over 20 years before her current role.