By: Kayla Groves, Billing & Coding Advisor, PECAA

Billing and coding are the foundations of your practice, and it is essential to understand how to bill correctly. Unfortunately, many practitioners are billing incorrectly, and the key culprit is underbilling. Whether this is due to lack of education or fear of an audit, it costs your practice thousands of dollars in revenue every year. That is why it is essential to understand the dynamics between vision insurance and medical insurance.

There are vital differences between vision insurance and medical insurance. This difference commonly occurs when the patient presents with a red eye and has vision and medical insurance. The patient has a $10 co-pay with vision insurance for today’s examination and a $500 unmet deductible with their medical insurance. The patient wants to use vision insurance for today’s examination because it will only cost them $10. However, if they use their medical insurance, they are responsible for the entire examination cost because they have not met their deductible.

The number one rule: Medical insurance should be billed for medical issues, and Vision insurance should be billed for routine eye examinations.

Medical insurance only covers health-related issues that they define or determine to be medically necessary. For instance, Medicare defines medically necessary as: “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.1

Each individual health plan defines what is considered a medical necessity. You need to understand the definition of medical necessity for each insurance plan your office accepts. They must be warranted by the health plan for your patient’s health or to treat a diagnosed medical problem regarding treatment, tests, and procedures.

How Can I Explain This to My Patient?

I know you came in here today for a routine eye examination, but you have an underlining medical issue that needs to be addressed before we can complete a routine examination for contacts or glasses. Because there is a medical issue that needs to be addressed, we will need to file your medical insurance, and you will be responsible for any co-pays or unmet deductibles.

Informing your patient during the exam allows the patient to decline medical care and opt for a routine eye examination. However, it is important to educate your patient on the risks of not treating a medical condition. It would be best to be transparent with your patients and not cause an alarm when they check out. Ultimately, leaving it to the patient to make the best decisions regarding their health. If your patient opts out of treating a medical issue, make sure you document this in their chart. Remember, it is always the patient’s choice to use their vision insurance if one of their complaints is refractive. If a patient has both a refractive and a medical complaint, you cannot force them to use their medical insurance for the exam.

Another approach is to address the issue of utilizing their vision insurance for a medical procedure.

If you utilize your vision benefits today, you will still have to pay out of pocket for a routine eye examination if you want to get glasses or contacts.

How Much Is This Costing My Practice?

For most patients who present with a red eye, you can use a level 2 or level 3 992XX evaluation & management (E/M) code or an intermediate 920X2 ophthalmologic code.

Typically, you are reimbursed better (usually significantly better) if the visit is billed to the medical payer. On average, you will be reimbursed two or 3x’s higher on a medical vs. a routine vision visit because a medical visit requires more intensive care. According to the AOA (American Optometric Association), the average Medicare fee schedule payment for the eye exam codes (92xxx series) was $114 in 2020, and vision plans typically paid $35-$90 for these services in 2020.2

Underbilling for your services could cost your practice thousands of dollars every year if you file vision benefits for a medical issue. It is essential to bill appropriately for your time and your skills.

How Is This Hurting My Practice?

Insurance companies want you to underbill for your services. That way, they can justify the need to lower reimbursements in the future. However, underbilling is very harmful to the Optometry field, and you should not advocate for lower reimbursements. Instead, your goal is to raise reimbursements. You can ensure this happens by coding correctly for the services you provided.

Should I Fear An Audit?

Did you know that down coding is just as bad as upcoding? Upcoding and down coding are both illegal and can result in fines or criminal prosecution. Optometrists must avoid down coding, and if an HCPCS (Healthcare Common Procedure Coding System) or CPT (Current Procedural Terminology) code that describes the services you performed exists, you must report this code rather than reporting a less comprehensive code.

It is crucial to have the proper education and knowledge to know you are coding correctly when it comes to billing. If you are coding correctly and providing the appropriate documentation, you should never fear an audit. If anything, it should be encouraged. It may help increase your reimbursements and help you avoid a future audit.

We all know an audit is something we want to avoid but remember that an audit is inevitable. You cannot prevent this from happening in your office. Even if you always code correctly, you will eventually have to endure this process. While you cannot prevent this from happening to your practice, you can avoid a negative outcome by billing correctly.

Also, keep in mind that the doctor is responsible for the coding, not the staff.

1. What Part B Covers. Accessed November 10, 2021.
2. Plans’ stagnant fee schedules undervalue primary eye care.

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