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Posted By kathy on 03-05-2002, 14:01:00 in Ophthalmology
We are from MI, If a patient comes in for a medical exam and then a
refraction is performed, we bill for the medical exam and the refraction is
rejected, can we bill the patient's vision coverage for the refraction?

Associates In Ophthalmology, P.C.
Comments (5)
Posted By douglas on 03-09-2002, 13:51:00
You are, I believe, exactly correct, that it depends not entirely on what is
the CPT definition, but what was taken into consideration when establishing
the RVU. If your suggestion were in place (three services: evaluation and
management with VA only, evaluation and management with BCVA, and evaluation
to recommend strength and type of lenses), there could be some unbundling.
But we already have too many fine distinctions between services, and the eye
codes are especially ill defined.

Given that there are only two types of available services in CPT (which I
refer to as the AMA's catalogue of services physicians provide), it is
necessary only to distinguish a medical exam from a refractive non-medical
exam. Given that division, I place BCVA as a necessary part of a medical
evaluation, and define refraction to include additional elements that are
needed to prescribe lenses. That's my rationale, but I agree that in an
ideal world, if you want to itemize services in minute detail, your approach
will work. But we already complain that having five levels of E/M services
already too finely divides the types of services. We might wish for only
three: quick exam, moderate exam, and full exam. If we start charging
separately for confrontation fields, BCVA, pupil testing, cornea exam,
conjunctival exam, etc., it would be too much administrative hassle,
wouldn't it. Then we would start to subdivide further - - the BCVA could
be present glasses give 20/20, no change with pinhole or with plus or minus
sphere. Or it could be a full and tedious refraction on a slowly responding
and inconsistent patient, so we need BCVA and extended BCVA. If you see
where I am heading. So I will pretend that the charge for VA or BCVA
included in an E/M service is an average of the two as you suggest.

Your question, however, might be directed to the RUC. When they assigned an
RUV, did it include BCVA. I suspect it never came up, because there already
existed 5 levels of E/M, and the job of the specialties was to define the
elements (and how many) that would make for the 5 levels. A simple formula
was used: 1-5, 6-8, 9-13, and 13+neuro/psych to define 4 exam levels, which
combined with other components ultimately define 5 E/M levels. Each exam
element has equal weight, so pupils are the same as cornea, acuity (VA or
BCVA?), optic disc, or alternate cover test. Obviously they are not equal,
as a cornea, conjunctiva, AC exam if normal together takes less effort than
the simplest bilateral VA, much less BCVA. We just assume that on the
average it works out. The general idea is simply to take our medical exams
and place them in a spectrum of 5 levels, sometimes with fuzzy or arbitrary
boundaries between them, and move on. We might wish there were only 3, or
as with eye codes, only two (or four, really).

Douglas R. Anderson
Posted By michael on 03-09-2002, 01:00:00

In a message dated 3/6/02 10:43:32 AM, writes:


A "best corrected visual acuity" (one definition of refraction) is part of

the medical examination to determine how much, if any, of imperfect vision

is due to a refractive problem and how much to a non-refractive problem.

This is a "diagnostic refraction", if you will. But not the refraction that

determines what type of lenses to prescribe, if any; that is, to fully

evaluate the refractive needs of the patient and make a lens recommendation

based on that. That takes more effort. >>

Dr. Anderson, this is an excellent point. But I wonder whether, when the E/M
or eye code system was set up, whether Medicare actually intended this
distinction, even though it makes sense. One would think that some time,
somewhere, Medicare or HCFA would have published a "clarification" of the
type you wrote about. The lack of such leads me to believe that the RVUs we
are paid for only include the measuring of a vision, not the determination of
refractive state, i.e., BCVA. If so, maybe we should have 2 charges: a lesser
charge to merely estimate the BCVA, and a greater charge when additionally
determining the optimum refractive correction for a patient, at least when
this results in additional work. But having multiple charges would be
confusing for patients, who wouldn't understand it. Imagine seeing a husband
and wife and charging them 2 different rates. they might walk away thinking
we didn't treat them eqiually and fairly. A better solution would be to
charge everyone an "average" amount that would reflect the average of the 2

Dr. Yaros
Posted By douglas on 03-07-2002, 15:52:00
Dr. Goldfarb,

Sorry if I misunderstood your initial message. I feared that a refraction
charge was being made on every visit on every patient, which some of our
colleagues do advocate. If you are charging for a refraction only on those
occasions when a genuine refraction assessment is done, as you describe in
this message, then we are on exactly the same page, and I'm happy for that.
As you point out, our function is to make the patient see optimally, and if
we get engrossed in evaluating and caring for a chronic medical ocular
condition and forget to evaluate refractive state from time to time, we are
not doing a proper service to our patients. Yep, I think we are pretty much
in agreement after all.

I would certainly agree that if new glasses are to be prescribed, the full
assessment should be done, rather than write a prescription based on a 4 or
5 year old assessment or prescription. Yes it takes time and deserves
payment. My "25 cent" comment referred to assuring the patient's present
1-year old glasses are fine, based on 20/20 acuity measured with them and
the patient's statement that his visual needs are all met. But he asks
casually whether I think he needs new glasses. Even though a refraction
recommendation (you don't need new glasses) was made, it was not enough
effort on my part that I would want to charge anything.

The lengthy discourse was really intended to get at something that comes up
over and over again, namely just what is a refraction. It seems that some
people (but not you) get confused by the fact that a diagnostic refraction
(best corrected acuity) and an evaluation in preparation for making
recommendations about lenses are two different animals, even if in everyday
speech we refer to each as a refraction. I took the opportunity of your
posting to expound on that, hopefully for the benefit of those on the list,
or perhaps to elicit some contrary viewpoints.

It is true that I have seen in print in an Academy publication in an article
on billing refractions that some of our colleagues advocate billing
refraction on every single visit, because indeed we do a best corrected
acuity (refraction) on every visit, and we lose revenue unnecessarily if we
don't bill for it, and moreover are even fraudulently including the
refraction in our medical visit charge if we don't. You and I just wouldn't
agree with that viewpoint. And I thought someone need to say so and explain
in detail. But here I go again, getting lengthy. Bye.

Douglas R. Anderson
Posted By douglas on 03-06-2002, 14:46:00
I disagree perhaps on one point.

A "best corrected visual acuity" (one definition of refraction) is part of
the medical examination to determine how much, if any, of imperfect vision
is due to a refractive problem and how much to a non-refractive problem.
This is a "diagnostic refraction", if you will. But not the refraction that
determines what type of lenses to prescribe, if any; that is, to fully
evaluate the refractive needs of the patient and make a lens recommendation
based on that. That takes more effort.

The "Refraction" that Medicare (and other carriers, depending on contract)
doesn't cover includes the determination of the type and strength of lenses
that will benefit the patient. It is more than determining how well the eye
can see given an optimal lens (best corrected acuity). Thus, history of how
satisfactory the present lenses are, what tasks are causing a problem
(reading, computer, driving, seeing movies, working with stamp collection,
playing a musical instrument), whether the person would find separate single
vision glasses for different tasks preferable to multifocal lenses, whether
working at a desk or prolonged reading suggests a wide reading add segment
is needed, or a narrow reading segment for those who play sports a lot and
only occasionally looks at watch or reads a score card. How much add? Where
does the patient find it most comfortable to hold reading material of the
sort he usually reads (newspaper may be different from a book, and I can
tell you from personal experience that +0.50 too much add makes it
uncomfortable to hold the book in an unnatural position, even though the
print is easier to read)? Should the full astigmatic correction be given,
and should one eye or the other be prescribed a lens in balance with the
other for comfort, compromising a letter or two. Is a slab-off needed? If
you straighten the axes, for example, you recheck the acuity to be sure that
the greater comfort does not compromise the acuity too much. Does the
patient want contacts, hard or soft, etc.? Monovision? All of this
constitutes an evaluation of the refractive needs of the patient, and would
generally result in a prescription. If a doctor prescribes from the best
corrected acuity without at least some of these evaluation steps, he did not
do a proper job for his patient, and you do see unhappy patients from
doctors who prescribed, without thought, the lens that gave the best
distance acuity with a guess at the add that will work for the patient.
Often it works out well, but sometimes you see a patient uncomfortable
because the doctor did not take care to do the additional evaluation and
thinking required. Often, these steps are fast, true enough, for a patient
whose history shows relative satisfaction with previous glasses, but if a
patient has a half-diopter myopic shift and complains only of distance blur,
but not having to hold material too close, you have to decide whether to
compensate the new more minus distance lens with a greater add so the
effective new reading segment is the same as now, or whether placing a minus
0.50 sph over present glasses makes reading still acceptable, so the power
of the add portion should remain the same.

So, an evaluation for the purpose of prescribing lenses is not the same as
performing a best corrected visual acuity. It thus seems incorrect to me to
charge for a refraction on every patient visit (especially those who come in
often to monitor a chronic disease like glaucoma) on the grounds that a best
corrected acuity was performed. Likewise, a refraction should be charged
when an evaluation leading to a recommendation about lenses is made. It may
be recommended that no lens change is needed, but that may have been based
simply on "Is the vision with your present glasses OK?" "Yes" and the
patient sees 20/20 with present glasses, but the patient asks, "do you think
my glasses need changing?", and without much thought you say, "No". I
don't think the 500 milliseconds it took me to assimilate that fact that the
acuity is 20/20 and the patient has no complaints about his present glasses
in order to formulate my "No" response to have a incremental additional
value of more than 25 cents added to the larger service being rendered
today. Now, if the acuity is 20/30 (cataract or mild ARMD), and I spent
some time with additional reading adds as low vision aids, but the patient
eventually preferred the blurred vision to the need to hold the material so
close, so no glasses were prescribed, well, it would be justified to say
that the patient was evaluated with regard to the type of lenses he might
(or might not) benefit from, and a charge rendered even though no
prescription was given. But, usually it comes down to whether a
prescription was rendered. And that's a fair-enough rule of thumb, it seems
to me, to be over-ridden on occasion by the doctor in cases like the last
one described. Fair dealing with the patient and third parties requires the
doctor to ask whether he rendered sufficient additional evaluation and
effort above and beyond the diagnostic refraction (best corrected acuity) to
helps him separate disease effects from refractive effects on vision. If
that additional effort is there, charge for a refractive evaluation.

I realize that some Academy publications have advocated, or at least
mentioned that some of its members have advocated, charging a refraction on
every visit, as Dr. Goldfarb suggests. Acknowledging and respecting that
opinions may differ, I myself do believe that a best corrected acuity is
part of an E/M service or the Eye Code, and that "Refraction" in the CPT
sense is something that takes some additional effort and thought by the
doctor. So I would advocate not charging a refraction on every patient who
comes in with an eye disease on every visit, but only when he comes in for
the purpose of obtaining glasses, or if being followed for an eye disease,
on those visits where apart from care of his eye disease, he gets for the
additional service of evaluating his need for lenses.

I'll get down from my soap box.

Douglas R. Anderson
Posted By douglas on 03-05-2002, 15:07:00
Well, may depend on the contract, and why the patient had the encounter.

If the patient comes in for evaluation of glaucoma, and while there mentions
that his vision is blurred so he needs new glasses, or that his glasses are
scratched and he wants a new prescription. If the primary motive for the
visit is to monitor his glaucoma, the medical exam will be paid. The vision
care may be a separate contract, and in some cases those contracted to
provide medical care may not be the same as those contracted to provide
annual vision care (the latter most often being optometrists). As the M.D.
in not in the list of providers for vision care, he may not be able to get
paid, especially without prior authorization.

But other insurances and plans are more flexible. It depends on the
contract. If a patient called up for an annual eye exam as part of their
vision care benefit, do they get an appointment with you? Or are they
referred elsewhere? If the latter, the third party may expect that when
your glaucoma patient asks for glasses, you say, "Oh, I don't do that for
XXXXX, because they have their own panel. You will need to make an
appointment with someone contracted for vision care in your plan."
Inconvenient, yes. But cheaper.

Douglas R. Anderson
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