Turning Problems into Profits

Billing Medical vs Routine Eye Exams

UPDATE: 

THIS EARLY BLOG HAS BEEN EXPANDED IN A MORE RECENT POST WITH A MUCH MORE COMPLETE DISCUSSION OF CODING EXAMS MEDICAL OR ROUTINE, AS WELL AS IMPLICATIONS FOR BILLING AND INCREASED PRACTICE REVENUE.  CLICK HERE.

 

When it comes to insurance 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.   Doctors who are seeking clarification on medical vs routine billing 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.  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.

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.