Article Date: 3/1/2001

CODING Q & A
Coding Q & A
Insights into accurate coding from a nationally known expert.
By John McGreal, Jr., O.D.

Q Is it necessary to bill separately for a refraction, or is this procedure bundled into the office visit?

Answer: As I'm sure you already know, in the Medicare program, refraction is a non-covered service. I know some of you bundle your refraction fee into the office visit, but as a Medicare provider, you have to charge your Medicare patients for all non-covered services and deductibles. So, it's necessary that you charge separately for refraction (92015). In fact, you must also make one attempt to collect on this claim if it's outstanding. Failure to bill Medicare beneficiaries for non-covered services and deductibles is considered fraudulent.

During an audit, Medicare can recoup monies from you when they determine that the services were inappropriately billed. For every exam that you don't charge the patient for the refraction, you'll pay a portion of the reimbursement back to Medicare. Why? Because Medicare will assume that you billed them for it because you didn't charge the patient. Typically, they'll assign 20% of the comprehensive exam and 33% of the intermediate exam as a market value for the refractive service.

Medicare can access your files from as far back as it likes. Think of how much it could cost if you had to pay a portion of the money back on each exam for which you didn't charge a separate refraction fee.

Also, from a practice management perspective, it makes sense to charge and collect the refraction fee from your Medicare patients when they check out of the office. If you don't, then you'll ultimately be denied payment when the claim is adjudicated by the carrier. Then, it's up to you to bill the patient after the fact. This simply delays your payment, increases your accounts receivable and reduces your profit by increasing billable staff hours required to generate a bill and mail it to the patient.

So, be sure to charge your Medicare patients separately for refraction. Also, collect fees from your patients before they leave. It will save you a ton of time, aggravation and money.

Q What code do you use when billing for corneal topography?

Answer: On the surface this seems like an easy question, but actually it's a little more involved than you may think. Unfortunately, corneal topography doesn't have a CPT code you can use in the Medicare program. However, corneal topography is billed using an unlisted ophthalmological service code (92499). The code will only work on commercial (non-Medicare) plans. Even so, your reimbursement for this procedure will be sporadic at best.

If you decide to submit a claim, remember that it requires a paper, not an electronic, claims submission. Also, you must attach a letter -- a medical necessity letter -- explaining why the procedure was necessary. These requirements take extra time for your staff and usually cost more than you're likely to be reimbursed.

You can always ask the patient to pay for the service, if you're sure the insurer will deny your claim for reimbursement. If this is the course you plan to take, have the patient sign a waiver of liability form so you can charge him for the procedure.

Q Are visual field codes considered bilateral or unilateral?

Answer: This is a common question I'm frequently asked. In the Medicare program many codes, such as visual fields (92081, 92082, 92083), are considered bilateral services. In other words, if you submit claims for these services, it's assumed that you performed the tests on both eyes.

If you've submitted a claim for a code that infers a bilateral procedure, but you've performed the service on only one eye, report the service with a -52 modifier indicating a "reduced service." Remember that this modifier is an informational modifier and not a reduced payment modifier. It won't result in a reduced payment, but it will give more description about the service you provided. 

Dr. McGreal is center director of the Missouri Eye Institute, a VisionAmerica Co-Management Center in St. Louis. He also lectures frequently on clinical and practice management topics.

If you have a coding question you'd like answered, send it to Terri Goshko, c/o Optometric Management, 1300 Virginia Drive, Suite 400, Ft. Washington, PA 19034. E-mail goshkotb@boucher1.com.


Optometric Management, Issue: March 2001