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Remember to bill refractions separately
I have retired from traveling around the country doing live presentations, but I do not think I will ever be retired long enough to not care what is going on in the optometric profession.
Dr. John Rumpakis and I have spent many years helping doctors and key staff people understand the logic of eye care delivery as well as issues related to medical record keeping and keys to accurate choices of codes for reporting eye care services. I am grateful that Dr. Rumpakis continues “fighting the good fight” to help ODs do the right thing.
I recently read an article of his that made me think that it will be awhile before Dr. Rumpakis can hang up his CPT and ICD-10 manuals and relax. The article was specifically related to billing for refraction, which should be simple enough to understand, but what saddens me is that in 2017 it is still necessary for Dr. Rumpakis to write such an article.
Twenty-five-year-old code
Please note: Refraction was given its own, unique code (92015) in the AMA Current Procedural Manual, the only national reference for procedure coding, in 1992. By my count, that is 25 years ago – 25 years of having its own code and, as such, being clearly defined as a separate ophthalmological service, distinct from all other services and, by definition, not included in any other service or any other CPT code. (Please note: HCPCS Level II codes S0620 and SO621, “routine eye examination, including refraction,” do include refraction in their definition.)
“Separate special ophthalmological service.” “Not included in any other service.” “Unique CPT code for reporting each time it is done.” How is it possible that there can still be eye doctors and some vision plans that are unaware of the 25-year-old change in CPT definition?
Sadly, I am not surprised. In my final year of writing and lecturing on these topics, I was challenged by doctors and staff many times, asked whether refraction could be billed separately. “Could be billed separately?” I would have replied, had I been bereft of common courtesy or totally unfamiliar with the profession’s difficulty in accepting change. “Shall be billed separately,” I might have replied.
As is very clear in CPT and has been stated from the podium and in articles countless times over the past 2.5 decades, a service should be performed if, in the doctor’s judgment, the service is necessary and, if it is done and is indeed a separate service, it should be billed. It is that simple. The only exceptions would be if the doctor has wittingly or unwittingly signed a contract that requires her or him to violate CPT rules and include refraction in a visit code and not bill separately.
Now, if we could get the last few vision plans and the last few thousand eye doctors and key staff to acknowledge the facts related to refraction as a separate service, I could totally retire, and Dr. Rumpakis could scratch this one thorny subject off his list of topics for articles and seminars.
Base exam, testing on needs of patient, doctor
By the way, if I had more time, I would get into another subject that should have been made clear years ago: Every health care provider should choose case history questions, examination elements and special testing based on the needs of the patient and on the needs of the doctor managing the case. In addition, the provider should choose codes for billing for visits and testing based upon the contents of the record for each visit. If special testing is done purely to verify something the doctor has been able to observe without the test, the test should not be billed.
I fear there are health care providers, including some eye doctors, who are “cruising for a bruising” by doing tests partially or totally to exercise their expensive instrumentation and, in rare cases, purely to augment their income. Mark my words, all of that will come to a screeching halt when audits by Medicare and other health care insurers increase in frequency and word begins to spread.
Am I holding my breath that these long-standing challenges are going away anytime soon? No. Sorry, Dr. Rumpakis. You cannot retire yet.
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- Charles B. Brownlow, OD, is a member of the Primary Care Optometry News Editorial Board and a retired medical records consultant. He can be reached at: brownlowod@gmail.com.
Disclosure: Brownlow is a retired health care consultant.