This article is more than 5 years old. Information may no longer be current.
News flash: Refraction has its own code, so bill separately
|
|
It is amazing how some habits can continue long after the basis for the behavior is removed or modified. The editorial board of Current Procedural Terminology, the sole authority with respect to definitions of medical services in the United States, removed “determination of the refractive state” from the definition of comprehensive ophthalmological service (92004/92014) in early 1992. The board gave refraction its own code (92015) in 1993. Medicare and most other payers quickly recognized the “refraction-ectomy” in the coding system, assuming that members of the number-one eye care profession in the country would catch on quickly. Were they wrong.
The only explanation I can offer for this Rip VanWinkle-esque behavior is that a few vision insurance plans continue to contract with eye doctors for something called a “routine eye examination” or an “annual eye examination,” characterizing it as something like, “comprehensive eye examination, including refraction.” These plans require their contracted panel doctors to report that service using the code 92004 or 92014, without the 92015.
Copyright violation?
CPT is copyrighted by the American Medical Association, and everyone using the CPT codes essentially agrees to abide by the definitions for all of the reported services. Doctors and payers who continue to include refraction in the comprehensive ophthalmological service, without reporting it separately, would seem to be guilty of a copyright violation of some kind. It is clear that the CPT editorial board is not concerned; I am not aware that they have contacted any of the offending doctors or payers requesting them to cease and desist.
Recommendations have not changed in 15 years
What can be so tough about this? See the accompanying chart for my recommendations for providing health care in 2007, which are basically the same as I would have recommended in 1997 or 1987. If you follow those guidelines, you will bill refraction — reported separately using its very own code, 92015 — every time you perform it. The only exceptions to this billing practice will be those dictated by your contract with the handful of vision plans that persist in incorrectly including refraction in the ophthalmological service.
For that matter, some vision plans require doctors to use the CPT code for comprehensive ophthalmological service (92004/92014), although the definition included in their contract with the doctor differs from the CPT definition. CPT has never defined the comprehensive ophthalmological service as either “routine” or “annual.” It is a medical service, just as most other CPT codes are.
Let me reiterate: The CPT definitions for comprehensive ophthalmological service and all other office visits do not include refraction. It is time for you to review your policy with respect to refraction and snap your practice right into the early 1990s.
Optometry reluctant
By the way, optometrists are the only health care professionals who are reluctant to bill for “not covered” services, such as refraction in Medicare. Any other health care provider would jump at the chance. Can you imagine a cosmetic surgeon or an orthodontist not charging separately for a procedure that is not covered? It is not very likely. Not covered means “cash on the barrel head,” no “30-day wait for payment,” no “insurance company negotiated reduction in payment.”
“Yeah, but doctors of optometry are different, right?” you might say. Maybe it is time to take a critical look at why you are different. You might find out that it is to your benefit to be a little less different. In many cases, being less different from other providers may even benefit your patient.
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 West Fulton St., PO Box 608, Waupaca, WI 54981; (715) 942-0410; fax: (715) 942-0412; e-mail: Brownlowod@aol.com.