Is Routine Eyecare Not Routine?
services we provide including care for contact lens patients may be
anything but routine. Here's how to differentiate medical from nonmedical when coding
By Charles B. Brownlow,
decades, eyecare professionals, especially O.D.s, have wrestled with the perception
that some of the services we provide are "routine," while others are considered
To compound the confusion, descriptions of these so-called routine
and medical services often look the same in a patient's medical record. Yet, due
to internal and external influences not the least of which is the patient's
history coding and billing for these services can differ significantly.
In this article, I'll discuss the most common Current Procedural
Terminology codes that classify these services and the criteria you should use to
differentiate between them for accurate coding and billing.
Contact Lenses to Aid Healing
Consider using contact lenses for the
remediation of eye diseases and conditions. For example, if a patient has recurrent
corneal erosion or a corneal injury and the doctor determines that a contact lens
should be applied to aid healing or manage the condition, use the CPT code 92070
for "Fitting of contact lens for treatment of disease, including the supply of lens."
The same holds true if the patient
enters with a "chief complaint/reason for the visit" related to a medical condition.
It may be appropriate to use a contact lens to promote the transmission of oxygen
in high levels to aid healing.
Anything but routine
has long been my contention that O.D.s do not perform routine examinations. Every
exam takes into account the overall health of a patient's eyes, including the surrounding
structures, the general well-being of the individual, and any ocular
or systemic medications he or she may be using.
So the term "routine" should be struck from the vernacular of
O.D.s and other eyecare professionals, and replaced with a more accurate description
of the services we provide.
Patient visits should be characterized as either:
Those for which there is a clear medical reason or chief
Those for which there is no clear medical reason or chief
The "Documentation Guidelines for the Evaluation and Management
Services," developed in 1997 by Medicare and the American Medical Association (AMA),
refer to only a discrete set of CPT codes: the 99000 series. For O.D.s, these usually
include office visits (99201-99205 and 99211-99215) and to a lesser degree, consultations,
hospital and nursing home visits and home visits.
Interestingly, neither the definitions found in CPT nor the documentation
guidelines mention "routine" services, so we can assume the codes are intended to
identify patient visits with a "medical chief complaint" or a "medical reason for
The other set of codes we use to represent patient visits (those
with a medical reason and those without) are in the 92000 (ophthalmology) series:
92002, 92012, 92004 and 92014. The CPT definitions for these services do not mention
"routine" services either. These codes are designed to report medical services,
which, in my opinion, should be defined as services for which there is a clear,
medical chief complaint or reason for the visit.
CPT codes must = CPT definitions
Occasionally, the AMA has had to remind providers and payers that
the CPT codes they use for services performed must correspond directly to CPT definitions.
In other words, no CPT code should be used to identify a service that does not match
the CPT definition for that service. If one or more elements of the definition are
missing, a different code must be chosen. Similarly, if at least one element of
the documentation guidelines is not present in the medical record, a different code
must be used.
In another example, if a healthcare plan pays for services that
are for treatment and management of medical conditions, no visit or other services
should be billed to that payer unless there is a medical reason or chief complaint
associated with the visit. In addition, when a patient reports to your office without
a complaint, the visit should be billed to the vision plan or the patient, even
if medical conditions are discovered during the visit. Once you've made a medical
diagnosis, subsequent visits and related services should be billed to the medical
Medical services explained
Eyecare professionals and payers continue to be confused about
the issues surrounding medical and nonmedical services even though they've been
hotly debated. The Centers for Medicare and Medicaid Services (CMS) explains the
difference between the two types of services for its carriers in the following the
The coverage of services rendered by an ophthalmologist (or optometrist)
is dependent on the purpose of the examination rather than on the ultimate diagnosis
of the patient's condition. When a beneficiary goes to an ophthalmologist (or optometrist)
with complaints or symptoms of an eye disease or injury, the ophthalmologist's or
optometrist's services (except for eye refractions) are covered regardless of the
fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her
ophthalmologist or optometrist for an eye examination with no specific complaint,
the expenses for the examination are not covered, even though as a result of such
examination the doctor discovered a pathological condition. (It continues ...) In
the absence of evidence to the contrary, the carrier may assume that an eye examination
performed by an ophthalmologist (or optometrist) on the basis of a complaint by
the beneficiary or symptoms of eye disease was not for the purpose of prescribing,
fitting or changing eyeglasses.
Defining the visit
Because our services depend on the purpose of the examination
and not on a patient's diagnosis, we should interview patients at the beginning
and throughout the visit, determine why they're in the office, and customize case
histories and examinations to match their needs. In each case, the doctor should
record the related diagnoses and management options resulting from the patient's
history and examination. Once the diagnoses and options are explained to the patient,
he or she should be released.
Doctors should follow each of these steps for all patients, regardless
of the patient's insurance coverage or lack thereof.
Only after the visit should you and your staff consider the patient's
insurance and determine whether the claim should go to the vision plan (if the chief
complaint/reason for the visit was nonmedical), or to the major-medical plan (if
the chief complaint/reason for the visit was medical).
What about CL patients?
When it comes to contact lens wearers, determining whether a visit
is medical or nonmedical poses another dilemma. Contact lens wearers occasionally
need a foreign body removed from a cornea or lid. They may develop other corneal
conditions related or unrelated to their contact lenses, including but not limited
to dry eye, glaucoma, blepharitis or macular degeneration.
It has been common practice to default to the routine side of
billing and submitting claims to payers. However, given Medicare's criteria for
assessing medical vs. nonmedical services, the contact lens patient should be treated
in the same manner as other patients, with the same rules applied, for determining
patient care and billing procedures for each visit. So always take these key steps
when contact lens patients come into your office:
Interview patients carefully at the beginning of the visit
and throughout to determine their needs. In short, identify each patient's "chief
complaint/reason for the visit."
Proceed with details of the case history and physical exam,
customized in order to discover the underlying cause(s) for the "chief complaint/reason
for the visit."
Record any diagnoses and management options that result
from the examination.
Submit the bill to the patient or to the patient's vision
plan if the "chief complaint/reason for the visit" is nonmedical.
Bill the patient's medical insurance plan if the chief
complaint/reason for the visit is medical in nature.
more, when patients report "chief complaints/reasons for the visit" that are medical,
even though all their previous visits were nonmedical, you should continue to consider
them as you had previously: as individuals in need of eyecare customized to their
CLs for therapeutic use
As you know, contact lenses are occasionally used therapeutically
to manage medical conditions. When this occurs, the visit and any appurtenant services
should be considered medical. The visit may be related to dry eye, keratoconus,
keratitis or another serious problem. In these situations, the patient's major medical
insurance probably will cover the visits and services provided because of the "chief
complaint/reason for the visit" classification even if the patient's policy
states it will not cover contact lenses or contact lens-
One often-misunderstood area of care specifically as it
relates to coding and reimbursement is contact lens fitting for keratoconus
patients. For most keratoconus patients, contact lenses are the only effective mode
of care. For others, they're an integral part of a broader regimen of care.
Thus, even payers that exclude all contact lenses from coverage
often cover visits and tests for keratoconus patients. Some health plans may exclude
patient care related to keratoconus, including lenses, visits and procedures, which
then become the patient's responsibility.
With other corneal and anterior segment conditions, such as eye
infections, dry eye, keratitis and recurrent corneal erosion, the insurance carrier
may not pay for the contact lenses themselves or any charges for fitting and management,
although it would pay for the visits and diagnostic tests involved in the identification
and management of the medical condition.
Reevaluating your practice
It goes without saying that the responsibility for following proper
recordkeeping procedures as well as coding and billing protocols rests with the
providers. This presents an important opportunity for you and your staff to provide
optimal care for all types of patients and get paid appropriately. To accomplish
this, you may want to reevaluate your internal coding and billing procedures to
ensure your office is basing its decisions on the rules and not on habit or unwritten
Understanding the differences between medical and nonmedical services
enables you and your staff to begin patient visits with open minds not with
preconceived notions about whether the patient's vision or major medical insurance
plan will pay for your services. Once you and your staff members understand the
rules and adopt clear protocols, everyone will be able to return to what they enjoy
most and do best: provide excellent eyecare for patients.
The articles that follow will discuss in more detail how contact
lenses, particularly silicone hydrogels, can be used to address certain patient
complaints and how these visits may qualify for reimbursement through vision
and major medical plans.
Dr. Brownlow is a nationally known lecturer and author. He's executive
vice president of the Wisconsin Optometric Association and president of PMI, LLC,
a consulting firm dedicated to eyecare professionals.
Optometric Management, Issue: August 2006