billing & coding
SOS on S Codes
guidelines for your practice.
and comprehensive eye examination codes, evaluation and management codes and consultation
codes are all options for billing office visits. There is also a good deal of confusion,
as well as potential misinformation, surrounding their use. Regardless of the patient's
situation, insured or private-pay, it is unlawful to have separate fee schedules
for the same services for different patient groups. Codes S0620 and S0621 for new
and established patients, respectively, are defined as "routine eye examination
including spectacle refraction." This differs from intermediate and comprehensive
eye examinations as defined by Current Procedural Terminology (CPT), which does
not include refraction. The refraction (CPT 92015) can then be billed as an additional
S-codes are a part of the Health Care Procedural
Coding System (HCPCS) and do not fall under the CPT guidelines. Medicare and other
federal health insurance companies do not recognize them. Currently, use of "S codes"
for comprehensive or routine eye examinations is limited amongst the eyecare provider
S is for serious
Those who favor S-codes for routine eye exams
feel they offer a competitive advantage or a legitimate way to provide a comprehensive
eye exam (including refraction) at a reduced fee for private-pay patients who present
without medical complaint or diagnosis.
While this may sound appealing if you
have a high number of private-pay patients in your practice (probably not more than
10%), consider the possible ramifications. Essentially, you will provide the same
services as with any comprehensive eye examination (CPT 92004 or 92014 with 92015
refraction), but you'll be charging less because the patient presents without insurance
or complaint. In the end, this will only benefit the managed care/insurance companies.
Consider: What if a patient presents with no complaints,
but you diagnose a corneal dystrophy or retinal degeneration, or macular edema in
a patient with 20/20 visual acuity who is unaware they have diabetes mellitus. These
medical diagnoses are not representative of the patient's chief complaint, so would
be qualified as a secondary diagnoses. Why devalue the eye examination by billing
for less just because the patient is private-pay?
The value of the comprehensive eye
examination does not change, regardless of whether the patient presents for "routine
care," with a refractive or medical complaint or without insurance. Charging a lesser
fee for the same services is simply dishonest and unlawful. Before using the S-codes
in your practice, consider all potential outcomes because there is considerable
misinterpretation and confusion surrounding their use.
ophthalmological examination including refraction
The S codes are used by private insurers to
report drugs, services, and supplies for which there are no national codes, but
for which codes are needed by the private sector to implement policies, programs,
or claims processing.
|CPT 92004 New
CPT 92014 Established
|Comprehensive Opthalmological Service
||This service includes history, general medical observation, external
and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination.
It often includes biomicroscopy, cycloplegia and tonometry. It always includes diagnosis
and treatment plans.
||Determination of refractive status
||This service may be billed in addition to a comprehensive ophthalmological
service or an evaluation and management service.
DR. MACK IS DIRECTOR
OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE
OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.
Optometric Management, Issue: August 2005