Comparison of OD and OMD eye examination

[Shnurek]

Mother went to an OD and I accompanied her. Her CC was "I'm having eye irritation." Got a diagnosis of macular degeneration ("I see some macular changes" "Take lutein supplements.") and dry eye. Gave her some systane artificial tears.

Mother went to her PCP and told her she went to an optometrist and the PCP told her to go see an ophthalmologist.

I accompanied her to the ophthalmologist. Her CC was "I'm having eye irritation." MD said "its normal with women after menopause" Gave her some systane artificial tears. Diagnosis: dry eye, macular degeneration. Then as we were about to leave I asked, should she take lutein?. He said yes, she can. Then we asked what dose. He said nobody knows how much should be taken. All went well until I saw the crazy costs that our insurance covered:

Eye exam with photos (92250) - $316
Eye exam, new patient (92004) - $508
Special eye evaluation (92020) - $104

Are these values normal? He did nothing different from the OD yet charged way more (I don't have the specific bill on hand but I can get it). $928 for an eye exam? Wow. If anyone is a NYC billing specialist, around how much can ODs charge for this type of eye exam if they have a fundus camera? I hope the Harkin Amendment gets implemented fast (scheduled 2014).

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[thiaeyemd]

He wont collect 928. He will get whatever the insurance negotiated rates for. Whatever is "billed" is just how much would be charged if a patient was paying out of pocket. The ophthalmologist gets nowhere near that amount. Blue Cross blue shied pays $700 for a blepharoplasty. My office will "bill" $2000. We will get a check for $700. The 700 reflects the negotiated reduced rate. It is done because as an oculoplastic surgeon, if I send a bill for $700 to Blue Cross Blue Shield, I will get a check for $300 back. (don't ask my why or how that makes sense...the insurance companies are bastards and don't play by the rules). The ophthalmologist is going to get the same reimbursment as the optom for the 92004. I am not sure what special eye evaluation is so and if he didn't take photos and billed for it, that is fraud.

 

[Jibslider]

92020 is the procedure code for gonioscopy.
92250 is the procedure code for fundus photos.

 

[Shnurek]

92020 is the procedure code for gonioscopy.
92250 is the procedure code for fundus photos.

o yes, he did a quick gonio (~15 seconds per eye) before instilling dilation drops. Maybe he did it instead of van herick b/c my mom has light eyes so hard to see? The OD did only van herick.

The ophthalmologist is going to get the same reimbursment as the optom for the 92004. I am not sure what special eye evaluation is so and if he didn't take photos and billed for it, that is fraud.

His assistant took one photo for each eye. I thought she'd do ISNT fields as well like I used to do for retina surg. Thanks for clearing this up.

 

[Jason K]

Mother went to an OD and I accompanied her. Her CC was "I'm having eye irritation." Got a diagnosis of macular degeneration ("I see some macular changes" "Take lutein supplements.") and dry eye. Gave her some systane artificial tears.

Mother went to her PCP and told her she went to an optometrist and the PCP told her to go see an ophthalmologist.

I accompanied her to the ophthalmologist. Her CC was "I'm having eye irritation." MD said "its normal with women after menopause" Gave her some systane artificial tears. Diagnosis: dry eye, macular degeneration. Then as we were about to leave I asked, should she take lutein?. He said yes, she can. Then we asked what dose. He said nobody knows how much should be taken. All went well until I saw the crazy costs that our insurance covered:

Eye exam with photos (92250) - $316
Eye exam, new patient (92004) - $508
Special eye evaluation (92020) - $104

Are these values normal? He did nothing different from the OD yet charged way more (I don't have the specific bill on hand but I can get it). $928 for an eye exam? Wow. If anyone is a NYC billing specialist, around how much can ODs charge for this type of eye exam if they have a fundus camera? I hope the Harkin Amendment gets implemented fast (scheduled 2014).

In NYC, Medicare pays:

$166.17 92004 New pt comprehensive exam
$90.54 92250 fundus photos
$30.36 92020 gonioscopy

Most medical plans will follow medicare levels, more or less. He's writing off the difference as a loss. Kinda funny he slipped gonio in there.

 

[grayscaleart]

the optometrist that did my eye exam charged me $308, i was like wtf!!! i have no specific complaints, free eye exams every year with my insurance. anyway, ODs charge a lot too. i think my insurance paid the full cost.

 

[Visionary]

Not sure why the gonio was done, unless the IOP was on the high end and/or the angles looked narrow. The 92004 and 92250 (or 92134 for OCT retina) are pretty standard for a new patient with macular degeneration, though. thiaeyemd and Jason are on point about the pricing.

 

[Shnurek]

Not sure why the gonio was done, unless the IOP was on the high end and/or the angles looked narrow.

I'll check her angles one day. Maybe she has a 1 or a 1+. Not sure what the cut off is angles for gonio before dilation.