When it comes to billing, optometrists live in a unique world where they are forced to juggle both routine and medical insurances, and this duality of payers causes frequent confusion for both doctors and patients. Over and over again we hear doctors ask, “When patients have both medical and routine insurance, who am I supposed to bill the office visit to?”
Over the years, we’ve heard all sorts of answers to this question. In fact, if you ask a panel of experts, you are likely to get as many different answers as there are people on the panel. The truth is only you as the rendering provider can answer this question, but there are important considerations that you should take into account, and we’ll try to help you explore these in this article.
First of all, let’s look at the two extremes: doctors who bill every office visit to medical carriers and doctors who bill every visit routine. Scenario One: This doctor knows medical exams pay twice as much as routine so he looks for reasons to bill the visit as medical. A lot of his patients seem to have headaches or dry eye, and 368.8 is a favorite diagnosis. Over coding medical exams is a questionable practice at best and puts a doctor at risk if he/she ever goes through a chart audit and the medical records don’t support this level of coding. Scenario Two is the other extreme: doctors who bill everything routine. If patients have routine vision insurance, some doctors feel obligated to use their benefit. Or the doctor may feel it’s easier to file routine rather than educate their patients about medical vision care or haggle over copays. However, there is a flaw in this reasoning as well. Doctors dealing with a complicated medical conditions have to spend significant additional time with patients– forming and outlining treatment plans, going over test results, and answering questions. They must bring all of their expertise and decision-making to bear, accumulated over years of post-graduate training and $150-$200K in student loans, and their professional risk certainly increases. Does it make sense at the end of this extensive examination that the doctor accepts the $40 reimbursement EyeMed, Davis, or Spectera is willing to pay?
So where is the reasonable middle ground that is both fair and ethical, and allows doctors to keep their doors open—something difficult to do on $40 eye exams. Doctors who are seeking clarification might be surprised to find a very good resource on this subject published by the largest routine payer in the industry, Vision Service Plan. Per VSP’s policy manual, how you bill the exam is driven by the patient’s chief complaint. The chief complaint should be the primary diagnosis on the claim, and this determines whether you bill routine or medical. For example, if patients present with no medical problems and report no medically-related symptoms and state the intent of their visit is to renew their glasses prescription, the exam is routine and should be filed to their routine carrier. However, patients who come in because they have glaucoma or macular degeneration made the appointment to monitor their condition, and these exams are medical. Similarly, if a patient with cataracts comes in because he/she can no longer see well enough to drive at night, then their chief complaint is directly related to their medical condition and the exam should be filed medical.
Please note that doctors cannot slack on their documentation with medical examinations. Medical conditions, related symptoms, high-risk medications, etc., should all be recorded in the presenting reasons for the patient’s visit. Objective testing that reflects standard of care should be performed and results reported in the record. And don’t forget documenting the treatment plan and patient communication.
Here’s another important consideration: Some patients’ medical insurance covers an annual routine eye exam. What do you do in this case? VSP guidelines say to bill the patient’s medical payer first and then coordinate with their routine plan.
So if you are a VSP provider, VSP has given you some very helpful and fair guidelines to assist you in deciding whether to bill office visits as routine or medical. Per their policy manual, you only bill VSP if the patient has no medical chief complaint and the patient’s medical plan does not cover an annual routine eye examination. That’s pretty straightforward and serves as a good rule of thumb for doctors when trying to traverse the confusing world of medical vs routine.
But there is one last tricky problem optometrists have to sort out: What if the doctor finds a medical problem during a routine exam? This can be a little more problematic and is a grey area for which there are few clear-cut guidelines. Generally, we’ve seen doctors follow one of two options. Option One: They explain to their patient that he/she has suspect findings and they would like to schedule a follow-up appointment for a more complete examination. When the patient returns, this exam will obviously be billed medical. Option Two: If they fear poor compliance, some doctors do not ask their patients to return for an additional visit. Rather, they proceed with the examination which they will bill as routine since that was the patient’s intent and there was no medical chief complaint. They do any additional workup to provide standard of care and cover their findings with the patient. Then they explain that because of the newly diagnosed medical condition, it will be critical to follow up every year with a medical eye examination, not just a routine glasses check. This changes the dynamics for the patient and the doctor. Because the medical condition is now documented in the patient’s record with a treatment plan for annual follow up, any subsequent visits are medical.
The key to any successful billing strategy is understanding your options and obligations, solid documentation in your chart records, and excellent patient education and communication.