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As we all know, routine eye care is generally not covered by health insurance, but may be covered by vision plans. A
key question in formulating the fee schedule in your practice is: should routine care have a lower fee than medical care?
The answer may depend on how you want to position your practice in the marketplace and on your local economy. While most
health plans do not allow a practitioner to charge different fees for the same service, there are two popular billing
policies that recognize the different circumstances involved in routine care. I'll describe those two policies, and then
we'll analyze if either is a good business decision.
Time of Service (TOS) Discounts
This policy has been in use for a long time and it provides for a discount whenever a patient pays the full fees at the
time of service. I'm not saying I advocate giving this discount, as we'll discuss later in this tip, but if a doctor was
so inclined, it could easily be justified for the cash-paying patient.
There is considerably more administrative work involved in billing a patient or a third party. There is also a delay in
the deposit of funds into the practice account and a risk that the balance will never be paid. Additional administrative
time may be needed to troubleshoot a rejected insurance claim and to pursue collection. Recognizing these factors, many
ODs provide a percentage discount to any patient or entity that pays on the day of service.
To document the reduced administrative service in these cases, the exam is typically coded with one of the 92XXX eye codes
and then appended with the -52 modifier. This modifier means reduced service, and in this case it refers to the
administrative billing service. It should be noted that modifiers do not apply to evaluation and management codes (99XXX).
This discount policy is offered to patients and insurance companies alike, although insurance companies obviously cannot or
will not wire the funds to be available at the time of service. While these services are not billed to insurance companies
(they are being paid at the time of service), the internal practice documents reflect that the fee charged in this case was
reduced and is not the usual fee for this service.
This relatively new set of procedure codes were developed as part of the HIPAA legislation. These codes are designed to
describe a "wellness" eye exam (whatever that is), and as such, they are not payable by health insurance plans. But it is
possible to charge a lower fee for this type of exam than is charged for a comprehensive eye exam with a medical diagnosis.
The theory behind this is that routine eye exams require less time or medical decision-making than medical eye exams.
Practices that use this code are not charging a reduced fee for the same service, but rather are defining a different
The two S-codes that would apply in this case are as follows:
S0620 Routine ophthalmological exam with refraction - new
S0621 Routine ophthalmological exam with refraction - established
I don't really like the idea of reducing the value of an eye exam just because the patient turned out to be normal and
healthy. In my view, a comprehensive eye exam still must be performed and there are a series of key tests that must be
run whether there is a complaint or not. I'm still going to do tonometry and a dilated fundus exam. I'm still going to
check binocularity and perform a slit lamp exam. A refraction with best corrected acuity is a must. I even feel the
practitioner must use the same professional judgment in the process of ruling out abnormal conditions. So, I don't really
get the S-codes; the time and expertise is still there.
Of course, we all provide different levels of eye exams, recognizing the depth of testing, and these have variable fees
commensurate with the service. But I don't do vision screenings in my office. If a patient has not been seen by an eye
doctor in the past year, I perform a comprehensive eye exam.
In my opinion, the best financial policy is to charge the same full fee regardless of insurance coverage or type of
diagnosis. Discounts fall directly to the bottom line and have a very negative effect on the practice. I know many
doctors feel their patients will balk at those full exam fees if they must pay out of pocket, but I have not found that
to be the case in my practice. I don't use either of the above policies. If practices with historically lower fees
gradually improve patient service and technology, the fee can be gradually increased at the same time with good patient
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
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Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
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