Optometric Billing-When To Bill Medical Vs. Vision Plans

  • By Andrew Roy
  • 26 Jan, 2016

Should you bill one plan or all the plans? Let the patient decide.

Optometric Billing Services

It's both a blessing and a curse the world we practice in. Many patients have both medical and vision plans that they carry for coverage and it's your job to know when to bill one or both of them. Effectively being able to do so will not only be beneficial to your practice and your bottom line but to your patient as well. 

Below, you will find a set of guidelines that you should follow in order to make this decision.  I must point out, however, that whenever you decide to go down this path it is imperative that you INVOLVE THE PATIENT IN THE DECISION MAKING PROCESS!  What do I mean by this? First,  simply having a patient sign a piece of paper declaring that you can bill whichever insurance you deem necessary is not enough, in fact it is NOT ETHICAL AND IT IS NOT LEGAL IN MOST STATES!  This is because you are taking away the patient's right to choose which benefits he/she wants you to use. Therefore, when making the decision to bill one or all of a patient's insurance plans you must verbally inform the patient of your intentions and make sure they understand and are ok with this. It is a good idea to have this conversation with the patient in the exam room. Tell him what you are thinking will be the best course of action based on his/her diagnosis and ask them if they understand and are ok with it. The patient will see that you care, both about their health and their pocket. 

Published in Optometry Coding Alert, October 2004

Click Here  to subscribe to latest Optometry Coding Alert.

Use the patient’s chief complaint and history of present illness to decide

When a patient has two kinds of insurance - medical coverage and routine vision coverage - billing the wrong carrier when you find a medical problem could put you at the wrong end of a fraud charge.

Along with their medical insurance, many of your patients might have supplemental private insurance - such as AARP Eye Health Services or CBIA/Aetna Vision One - to cover routine eye examinations. When you find a medical problem like cataracts or glaucoma while doing a routine eye exam on these patients, you have a dilemma. Should you bill the patient’s medical insurance, since you found a medical condition? Should you bill the patient’s vision insurance? Or can you even bill both?

Bill Medical Coverage if There Is a Complaint

The answer depends on the patient’s reason for being there, says  Becky Ross, billing specialist for Eye Q Vision Care in Fresno, Calif. Bill based on the patient’s chief complaint and history of present illness (HPI). If he has a specific complaint that can be attributed to a non-refractive diagnosis, then it’s a medical visit and should be billed to the medical insurance, Ross says.

Example: A patient arrives complaining of blurred vision. You find that cataracts are causing the blurriness. Bill the patient’s medical insurance with the appropriate eye exam code (92002-92014) and link it to the appropriate cataract code (366.xx). As a secondary diagnosis, report 368.8 ( Other specified visual disturbances [blurred vision NOS] ). If, however, you found no cataracts or any other condition causing the blurred vision, report 368.8 as the primary diagnosis.

Bill Routine Coverage if There’s No Complaint

What if the patient doesn’t have a complaint? The rule still holds: Code according to why the patient is there. If the patient comes in with no specific complaint, but you diagnose a medical problem, report the routine visit as the primary diagnosis and the medical condition as the secondary diagnosis. Bill that visit to the patient’s vision carrier, says  Tuija Kaarrekoski, billing specialist with the Seattle Eye Center.

If there is a follow-up exam later, the medical condition will be the primary diagnosis and the bill goes to the patient’s medical insurance.

Example: A patient comes in for the routine eye exam that his vision insurance provides and has no complaint. You discover bilateral nuclear sclerotic cataracts. Bill the patient’s vision insurance with the appropriate E/M code (99201-99215) and link it to ICD-9 code V72.0 ( Special investigations and examinations; examination of eyes and vision ).

As a secondary diagnosis, report 366.16 ( Senile cataract; nuclear sclerosis ).

Bill Both When Performing Extra Diagnostics

If a patient presents with no complaints, but you find something that makes it necessary to perform tests in addition to the routine screening, you may be able to bill both the medical and the visual insurance.

Example: A patient is in for a routine exam and has no complaints. As part of your exam, you find intraocular pressures of 30 mm Hg in both eyes and suspicious cupping. You perform extended ophthalmoscopy and visual fields but find no glaucoma.

Since the patient had no complaints, you would need to bill the patient or his vision plan for the initial visit, however brief or comprehensive, says  David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. But you could bill any additional tests as medical, even if you perform them on the same day.

Bill the eye exam with the appropriate eye code to the patient’s vision insurance. Bill 9208x ( Visual field examination, unilateral or bilateral, with interpretation and report;  …) and 92225 ( Ophthalmoscopy, extended, with retinal drawing, with interpretation and report; initial ) to the patient’s medical insurance. Link the CPT codes to ICD-9 code 365.01 ( Borderline glaucoma [glaucoma suspect]; open angle with borderline findings ) - or the appropriate 365.xx code if you found glaucoma.

“What you absolutely should not do is bill both companies for the initial exam,” Gibson says. “That is fraud. But billing the routine exam to the patient and extended ophthalmoscopy and visual fields to the medical insurance keeps you honest and able to defend an audit.”

The Optometric Billing Spot

By Andrew Roy 21 Nov, 2017
Up until recently, there have not been any effective patient-derived models in which researchers can test for treatments in regards to macular disease. However, this has possibly changed as researchers have been able to re-program stem cells with three different forms of macular dystrophy. After aging them in a dish these cells mimicked several characteristics of the disease, allowing for scientists to begin working with a human stem cell model. Rebecca Hepp dives into detail in how these research models have paved the way for innovative treatment research. How does this review of optometry affect your optometric billing?
By Andrew Roy 15 Nov, 2017
Ocular surface disease (OSD) management is driving technology to get ahead of the game. This means educating and diagnosing patients in a more timely manner in order to motivate them to start and maintain their treatment. John Rumpakis, OD, MBA, discusses how these new technological advances in imaging, though resourceful, may or may not be billable for insurance companies. How does the coding in these diagnoses affect your optometric billing?
By Andrew Roy 09 Nov, 2017
Optometry is advancing every day in this ever-changing world, and so is the world-wide industry of classic clinics. Brooke Messer, MD, explores the challenge of building a niche practice--that is, building a practice based on that of a certain specialty, such as contact lenses. This type of practice can yield great emotional and financial rewards while making connections between you and your patients. Many resources are made available at your fingertips while bringing a new dimension to the practice when beginning to train staff. Investing in technology can go a long way in building your patients loyalty. How can your optometric billing help build your specialty practice?
By Andrew Roy 24 Oct, 2017
The U.S. prevalence of glaucoma in patients is suspected to rise 6.3 million by 2050. Jarett Mazzarella, OD and Justin Cole, OD write about how integrating newer technologies into optometry practices can help detect signs of early glaucoma and how it is integral for providing data to diagnose and begin early treatments. Clinicians can use many tools such as corneal hysteresis, OCT angiography, visual field testing and electrodiagnostics to help better detect the signs and begin treating patients to prevent them from going completely blind. How does modernizing technologies for detecting disease affect your optometric billing?
By Andrew Roy 20 Oct, 2017
Advances in clinical technology are helping optometrists to sooner detect diseases that may otherwise be undetectable. Last month a patient of Paul M. Karpecki, OD, without symptoms and 20/20 vision, was found to have a significant peripheral malignant melanoma. Upgrading basic tools such as handheld instruments and refractor systems can help in the early diagnoses of most life-threatening diseases; diseases like AMD (age-related macular degeneration) or glaucoma, for instance. Optometry is embracing new innovative technology in order to improve diagnostics. How can upgrading your diagnostic tools transfer into more robust optometric billing?

Click here to read more.
By Andrew Roy 13 Oct, 2017
Optical coherence tomography (OCT) scanning has come a long way in the development of its technology in the last two decades. Through new software updates such as swept source (SS), the OCT can provide higher image acquisition speed and less variation in sensitivity. Instruments now have Anterior and Posterior Segments available for use along with enhanced depth imaging. OCT angiography allows the detection of movement to be seen at higher speeds. Dive into the world of today’s optometric technology knowing how to navigate through these exquisite tools. How will these new advances in OCT affect how you practice optometry and your optometric billing?

Click here to read more.
By Blog Owner 17 Jul, 2017

Melanie Denton OD, MBA, FAAO recently wrote and article for optometry times relating to the "insurance game". She is 100% right...INSURANCE IS A GAME and unless you learn the rules your practice will never be as successful as it could be, it's just that simple.

One of the biggest things she points out is sometime I've been telling clients for years: when it comes to your insurance billing it's important to STAY INVOLVED! This doesn't mean to hang over your biller's shoulder and check every little thing they do. It means learn and understand the process and the intricacies so that you can have informed and intelligent conversations with your biller and/or the insurance companies. If you know how things work, you'll be that much better prepared to check up on things, make adjustments when things go wrong and make intelligent and informed decisions about the direction your practice is going.

I have included an excerpt of her article below. You can always click the link to read the whole thing.

I know exactly how insurance is billed at my office. Is that the best use of my time?

This is how we get paid, so I think staying involved is a good idea right now when our patient load is smaller.

Staying involved is also effective in making sure that as a practice we set things up correctly. I have watched countless YouTube videos about CMS 1500 forms and how to fill them out, how to read explanation of payment forms, and clearinghouse-specific training.

Related: Defining success: Is more better?

I know how our practice management system interfaces with our clearinghouse, and often I send the claims myself. In the setup period, it is critical to be attuned to the details.

Even if your practice is well-established, it is important to spot check claims and ensure that they are completed correctly not only to ensure your revenue stream is what it should be but also to guard against potential audit concerns.

Related: Behind the scenes of Instagram practice photos

In addition, staying involved helps me to know which commercial carriers are excluding us from specific panels without telling us. (Sometimes PPO or HMO panels require a primary-care referral first or require your participation on that specific sub-panel).

There is no shortcut to setting up your office for the first time on insurance panels. The process is time consuming and at times maddening. Some of the companies we are now regularly taking payments from took six to eight months to credential us.

This is a marathon, not a sprint. Don’t take no for an answer. Fight the good fight.

By Blog Owner 01 May, 2017
Dear Readers, A quick note today:

Whenever you bill a surgical procedure to insurance (any procedure that begins with a '6') you MAY NOT bill an exam to that insurance company for the same day as insurance considers an exam to be PART OF THE SURGICAL PROCESS!

However, if you have a significantly DIFFERENT DIAGNOSIS CODE you may append the exam procedure with a -25 modifier and bill the insurance for both the exam and the surgery so long as the diagnosis code being used for surgery is ONLY POINTED TO THE SURGERY and the diagnosis code for the exam is ONLY POINTED TO THE EXAM!
By Blog Owner 24 Apr, 2017

Primary Eyecare:

"Everyone will come to you and you will be the one who refers them to different specialties". Maybe the eyes are more than just a window to the soul?
By Blog Owner 18 Apr, 2017
It has become a fact, especially since the introduction of "Obama Care", that doing billing in house is more costly than outsourcing. Not necessarily because the cost of salary is higher but because, and this is specifically unique to optometry, most new and small to medium sized practices don't have the man-power or resources to dedicate one person or a group of people specifically to the task of insurance billing. The result is that collection rates rarely exceed 73% of available money from insurance/patients. EVERY ONE of our clients achieve a 93% collection rate within 2 years; typically much faster if that practice owner is willing to let us "run the show" and defer to us when it comes to making decisions and implementing policies regarding insurance billing. This means that your practice will instantaneously be more profitable as a result of your decision to outsource which in turn means that you are spending less money doing so.

More Posts
Share by: