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Certain office visits for contact lens patients can be billed as ‘medical’
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Eye care providers, especially doctors of optometry, are often faced with a dilemma when it comes to billing for their examination services and procedures: Should the visit be considered “medical” and billed to the patient’s medical insurer, or “nonmedical” and billed directly to the patient or to the patient’s vision insurance plan? The challenge becomes more acute as deductibles rise for most major medical insurance plans and as patients strive to maximize their benefits and minimize their out-of-pocket expenses.
As with many challenges facing health care providers, this one is best met head on, with advance consideration and planning and with established in-office protocol to be sure that all doctors and staff deal with patients consistently.
Medicare policy is clear
Medicare Part B has a clear policy: Medicare never pays for services unless the patient entered the office with a medical reason or complaint.
Specifically, Medicare’s policy is “Routine Care Exclusion: Medicare does not cover routine physical checkups, eyeglasses, contact lenses and eye examinations for the purpose of prescribing, fitting or changing eyeglasses, and refractions.” (Section 2320, Medicare Carriers Manual)
Section 2320 goes on to explain the policy in greater detail: “The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury, and (b) examinations required by third parties such as insurance companies, business establishments or government agencies.”
It may be helpful to rephrase section (a) to state it positively: Medicare does not cover examinations unless for a specific illness, symptom, complaint or injury.
Section 2323 of the Medicare Carriers Manual continues to guide coverage decisions as it states: “The coverage of services rendered by an ophthalmologist is dependent upon the purpose of the examination, rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist’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 for an eye examination with no specific complaint, the expenses for the examination are not covered [emphasis added] even though as a result of the examination the doctor discovered a pathologic condition.
“In the absence of evidence to the contrary,” Section 2323 continues, “the carrier may assume that an eye examination performed by an ophthalmologist on the basis of a complaint by the beneficiary or symptoms of an eye disease was not for the purpose of prescribing, fitting or changing eyeglasses.”
In other words, if a visit is the result of a complaint by the patient or symptoms of eye disease, it is billable to and payable by Medicare. Therefore, if the patient enters the office without a medical complaint or without symptoms of an eye disease, the visit should be billed to the patient or, where applicable, to the patient’s vision plan.
Applying Medicare’s rules to your practice
Keep in mind that the reason for the patient’s visit might not be apparent at the beginning of the encounter. Often, a patient will not state his or her complaint or symptom at the time the appointment was made. Sometimes, they do not even admit they have a problem during the preliminary case history.
It is up to the doctor to decide during the visit whether the true reason for the visit was indeed centered on a medical complaint or symptom or the patient was seeking a general examination or was experiencing refractive or other nonmedical vision-related symptoms. The call is made clearer when the staff and doctor listen carefully and are well aware of the rules for making the medical vs. nonmedical/refractive decision.
The next challenge related to deciding where the bill is going is explaining this to the patient. This is also much easier if you have a clear policy in your office and especially if you use the Medicare policy as the basis for your own. This permits you to explain it to the patient by citing a national rule and your dedication to sending claims to the appropriate payer.
Your policy should not be based upon minimizing your patients’ out-of-pocket expenses. The insurance plans are the patient’s plans, not yours. The rules are the insurers’, not yours. Your job is to provide excellent care in a confusing and progressively more convoluted system. You are simply doing your best to send the bill or claim to the person or company who is responsible for payment.
Case examples
Consider a few specific challenges that face eye doctors. A contact lens wearer comes in with giant papillary conjunctivitis. The complaints and symptoms will clearly be medical, even though the patient happens to be a contact lens wearer. Barring specific contracted exclusions for “contact lens-related” eye problems, this represents a medical reason for visit/presenting problem and would appropriately be billed to the patient’s major medical insurer.
In a second illustration, a patient is diagnosed with keratoconus and requires a “medically necessary” contact lens. Keratoconus is clearly a medical condition, and the care of the patient should be billed to his or her major medical insurer. In doing so, the eye doctor must realize that many medical insurers consider all contact lenses and their related care to be “routine” and not payable. The payer may reject the claim out of hand, requiring resubmission of the claim, possibly with additional supporting documentation.
In any case, the office should be sure that the patient understands the insurance dilemma and is given the opportunity to sign an Advance Beneficiary Notice acknowledging the potential denial by the insurer and agreeing to pay for the care if the insurer rules the care to be not “reasonable and necessary.”
When dealing with insurers, you can be right and still have a claim denied. You can be confident that the keratoconus is a medical condition, and the insurer can consider it to be contact lens related and deny the claim. Again, the insurance policy is the patient’s responsibility. Your responsibility is primarily to provide excellent care to the patient and, secondarily, to comply with any rules imposed by any contract you have signed with specific payers.
In the first example, once the medical condition is resolved, the contact lens care reverts to being nonmedical, and any refit or follow-up care for the contact lenses themselves would no longer be billed to the major medical.
Some insurers’ definitions differ from national guidelines
Coding for the care – medical or nonmedical/refraction – should be the same, unless the insurer has its own requirements, some of which do not follow the rules established by the definitions in Current Procedural Terminology or in the Documentation Guidelines for Evaluation and Management Services.
It should be no surprise that some vision plans include definitions of services in their contracts that do not match nationally accepted definitions, and many major medical insurers also seem to change definitions and interpretations occasionally. The only effective method for dealing with those challenges is to consistently choose codes based upon the national standards, straying from them only when specifically contracted to do so.
As the system continues to grow more chaotic, doctors’ only port in the storm is to create clear and solid office protocols for dealing with the challenges and to base those protocols upon national standards whenever possible. When you are armed with those resources, your arguments and discussions with insurers and patients can stay on a high plain and be far less frustrating for everyone involved.
For more information:
- Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board, executive vice president of the Wisconsin Optometric Association and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., P.O. Box 608, Waupaca, WI 54981; (715) 942-0410; fax: (715) 942-0412; e-mail: Brownlowod@aol.com.
- A good source for the only three key national references, Current Procedural Terminology, The Documentation Guidelines for Evaluation and Management Services and International Classification of Diseases, 9th Edition is Codes for Optometry, available through the American Optometric Association Order Department: (800) 365-2219.