Article Date: 9/1/2003

coding q & a
Charging for Refractions
Understand Medicare's refraction rules and you'll receive the most benefit.
By Suzanne Corcoran, C.O.E.

Refraction is the most common diagnostic test in eye care. Even so, many eyecare practitioners have questions.


Q Does Medicare cover refractions?

Medicare doesn't cover refractive services because they're excluded by law. Further, if a Medicare patient presents with only a refractive complaint (e.g., "I need new glasses"), then the exam also isn't covered -- even if the doctor detects disease during the exam.

"The coverage of services rendered by an ophthalmologist is dependent on the purpose of the exam rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to an ophthalmologist with a complaint or with symptoms of an eye disease or injury, the ophthalmologist's services (excluding refractions) are covered regardless of the fact that he only prescribed eyeglasses.

However, when a beneficiary goes to his ophthalmologist for an eye examination with no specific complaint, the expenses for the examination aren't covered even though as a result of such exam the doctor discovered a pathologic condition." The same statement applies to optometrists.

Q What about non-Medicare payers such as HMOs and PPOs?

Whether other third-party payers cover refractions is a matter of contract. When you sign as a provider of services with a plan, you should be informed about its policy regarding refractions. It's sometimes difficult to find the information buried in the policy. If it isn't clear, then pursue the question until you get an answer.

This is important from a financial standpoint. Many HMO and PPO plans pay a percentage of Medicare. Determining whether you can collect your usual refraction fee in addition to the exam may make the difference between accepting a plan or not.

Many payers have multiple plans, some of which bundle the refraction and some of which don't. It's important that you find out which of the plans you participate in allow you to collect separately for refractions and that your office staff have this information. Otherwise, you may leave money on the table.

Q Once we set a refraction fee, must we charge everyone the same?

That's a good question. As far as Medicare is concerned, it has no requirements one way or another. Medicare doesn't even care if you decide not to charge. Private insurers may have different rules; check your contract.

Q Can a technician perform refractions on patients when the doctor isn't in the office?

Medicare doesn't publish any instructions about supervision of refractions because this service isn't covered. However, we can infer that the service requires the presence of the physician at the time the refraction is rendered for the following reasons:

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.


Optometric Management, Issue: September 2003