BUSINESS: Coding Strategy

Navigating Billing

Is today’s visit appropriately billed using the patient’s vision plan, medical plan or both benefits?

What do you do when a patient comes in to your practice with the intent to use her vision plan and you discover she has a medical problem? Well, that depends. This is a real scenario that happens daily in most optometry practices. The good news: Most of your vision plan contracts define the answer.

During my time as a medical records auditor for Florida Medicaid, I found that providers were, at times, incorrectly billing both the vision and the medical plan for the same procedure code or diagnostic test rendered on the same day of service. And, because the providers were paid by both insurers, these optometrists believed that what they were billing and getting paid for was OK.

The truth is, it is not OK. Duplicate payment for one service constitutes overpayment and may even become escalated to criminal fraud if a pattern of this type of behavior persists. However, honest mistakes do happen, and proper payment statement reconciliation forms are a safeguard to ensure compliance. So, in the event that any billing and payment error has occurred, insurance companies allow a grace period (usually up to 60 days) for the provider to return the overpayment — with a copy of the claim and explanation — during which the provider suffers no penalty or interest.

Ultimately, your safe billing practices can be identified via the question “What does my contract say?” This document should serve as your best answer to the question, “Is today’s visit appropriately billed using the patient’s vision, medical or both benefits?” It is important to look at each contract, as the rules may differ.


EyeMed says, at : “If the patient initially lacks a specific complaint related to a medical condition, it is most appropriate to bill the vision plan (EyeMed) for the visit.”

VSP says, at : “Bill according to the reason the patient stated for making the appointment (chief complaint). If, during the course of the routine exam, you discover a medical condition, you should still report and bill the visit as routine. You can then follow up with additional services and/or procedures, as appropriate, to treat or monitor the pathology and bill the appropriate medical CPT codes.”


A patient tells your staff she is at the office to determine whether she needs a new prescription for her contact lenses and glasses. Then, as the doctor enters the exam room, the patient discloses that she also has diabetes. In this case, due to Healthcare Effectiveness Data and Information Set (HEDIS) incentives, you have options. Ideally, your staff will have verified your patients’ medical and vision benefits and determined ahead of time that the patient has both a vision benefit and diabetic retinal screening test coverage. In this case, you can proceed as you are, billing the vision plan for the exam and the retinal screening. If, during the exam, you determine the patient has diabetic retinopathy and needs further testing, such as an OCT, you could schedule that patient for a return visit, during which time you would bill the medical plan for medically necessary services or testing.

What if: A patient presents for a wellness visit and then you discover a medical problem? Can you bill for special testing, such as OCT or VF, on the same day? You may bill the special testing component to the medical plan, charge the patient her medical copay and bill the comprehensive eye exam to the vision plan. What would not be acceptable would be to bill both the vision plan and the medical plan for the comprehensive exam.

Another scenario: A patient schedules her appointment, reportedly to renew her contact lens prescription. When she arrives at the office, she has a red eye that needs medical eye care. In this situation, notify the patient that the medical problem needs to be treated, and the contact lens evaluation postponed, until the medical problem is resolved. I would then notify the patient of the fees associated with the visit under the medical plan and proceed as medically necessary for the patient.


  • It is important that you follow the terms of your contract when determining your response to billing questions and then determine how to best present the information to the patient for better patient communication.
  • Verify all benefits, medical and vision, before the patient arrives, so you are ready for the unexpected. Have a document you present to the patient in writing outlining the benefits and explaining the difference between medical and vision plans.
  • If a visit does need to be billed medically, be honest with the patient before the exam begins or at the time the problem is discovered.
  • If you perform both medical testing and a well visit on the same day (allowable in some situations), do not bill both the medical and the vision plan for the same visit. In this situation, you’d bill the special testing to the medical plan — but don’t forget to collect that copay at the time of visit. (Of note: Routinely waiving patient copays may be viewed as a “kick-back” to the patient and should, thus, be avoided.)
  • If in doubt, call and ask the insurer how to proceed: Document the name of the plan, representative name, date and time of your call and advice given to you. OM