KNOW WHEN TO CODE FOR AND CHARGE FOR THIS FUNDAMENTAL SERVICE
ONE WOULD think coding for refraction is fairly simple. Yet, I see a fair number of issues that arise. According to the CPT, there is only one code associated with refraction: 92015 — Determination of Refractive State. There are no other codes within the CPT system that specifically define refraction.
There are two service codes, specifically, HCPCS Level II codes, S0620 and S0621, that include refraction as part of the service. The ophthalmic examination codes (920XX) and the evaluation and management codes (992XX) do not include refractive services, so 92015 must always be coded as a distinct and separate service when it is performed.
KNOW THE CODE
One of the most amusing (and concerning) errors I have heard and seen in audit reviews, is the claim to have performed “a medical refraction” or a “complicated refraction.” To be clear, there are no such things in coding.
I remember one situation, where the O.D. specifically told a group he coded complicated refractions using code 92018 and was charging in the “hundreds of dollars” for it, to which I asked what agent he was using for general anesthesia to perform the examination.
You see, 92018 is not for a “complicated refraction,” but is specifically defined as “Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete.” Obviously, he was not using the CPT correctly — he just thought the higher the number 92015, 92016, 92017, 92018 — the more complicated the refraction.
Determination of Refractive State
- SO620 & S0621
HCPCS Level II service codes that include refraction as part of the service
- 920XX & 992XX
Ophthalmic examination codes for the evaluation and management, respectively; do not include refraction.
CODE AT TIME OF SERVICE
Coding for refraction should occur when — and at the frequency — the procedure takes place, just as when you repeat any other procedure.
There is not a “global period” or “guarantee period” for refraction. If you repeat the procedure for determining the refractive state on a patient, then you should code and bill for it, irrespective of who the responsible party is: medical insurance, managed vision care plan or patient.
In addition, it is important to be specific about the difference between performing a refraction and issuing a spectacle or contact lens prescription. Not all refractions end with a prescription, yet they remain a refraction.
A prescription is what occurs when you, as the physician, take a whole host of information and use your education, expertise and experience to transform the patient’s refractive state in the form of a spectacle lens or contact lens. As an example, you may perform on an individual patient a number of refractions where they have a fluctuating refractive endpoint, yet you only feel comfortable writing a prescription once they have stabilized. Does that mean you should charge only for the “final refraction” or should you charge for each refraction?
When you perform a refraction, you are performing a service that is describable by 92015 and should be coded and billed. The code does not describe determination of final refractive state, but simply where you determined the patient’s refractive state to be at that specific point in time.
UNDERSTAND PLAN REQUIREMENTS
Medicare does not pay for refractions as they are statutorily excluded from coverage. You should still submit the refraction to CMS as many secondary insurances need the rejection from CMS to process the claim.
Generally, there is no modifier required when you are submitting a refraction to CMS, however some CMS carriers require a modifier and in those cases the modifier would be GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
REFRACT AND COLLECT
Refractions are a fundamental service we provide and the CPT clearly describes. Knowing when to code for and charge for a refraction is essential to the success of your practice. OM