eye exam

[PBEA]

what do SDN MDs and ODs think a "routine eye exam" is? Any perspective (philosophical, coding and billing, clinical, etc) is welcome.

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[orbitsurgMD]

Vision, distance and near with present correction (and lensometry); Pinhole acuity, Refraction if requested or if vision is less than 20/20 in either eye uncorrected or with present correction or if complaints typical of aesthenopia or other accommodation-related conditions (convergence insufficiency, esotropia, etc.)

Motility, including assessment for strabismus
External Examination, including cranial nerve assessment if indicated
Confrontational fields
Pupil Examination, including examination for APD
Tonometry
Slit lamp examination of adnexae and lids, conjunctivae, corneas, anterior chamber, irides and crystalline lens; posterior segment examination of vitreous, optic nerve, macula, retinal vessels and retinal periphery, by indirect ophthalmoscope BIO and slit lamp BIO

Refraction is customarily billed separately when done (and excluded from covered services by many carriers except post-cartaract).

Billing for extended retinoscopy with detailed drawings is also billed separately when done but is commonly paid only when a complaint indicates (or not paid even when the complaint dictates, if you have Aetna.)

Static perimetry is not included.
Standard Color plate examination may be included; specialized color vision exam (SPP2, Lanthony 40, FM100, etc) is not included in a routine eye examination
Stereopsis testing may be included (Titmus Fly or circles).
Photography is generally not included, including angiography
Ultrasonography is not included
Scanning laser ophthalmoscopy (or scanning laser tomography) is not included
Pachymerty is not included
Gonioscopy is not included
Sensorimotor examination may be billed separately
Surgery or any instrumented treatment (e.g. forceps epliation) is not included

I did not include the required history: cc, current and past history, ROS, FH, occupational history, EtOH, drug, allergies; I am assuming those are collected as well.

 

[bucknut101]

Vision, distance and near with present correction (and lensometry); Pinhole acuity, Refraction if requested or if vision is less than 20/20 in either eye uncorrected or with present correction or if complaints typical of aesthenopia or other accommodation-related conditions (convergence insufficiency, esotropia, etc.)

Motility, including assessment for strabismus
External Examination, including cranial nerve assessment if indicated
Confrontational fields
Pupil Examination, including examination for APD
Tonometry
Slit lamp examination of adnexae and lids, conjunctivae, corneas, anterior chamber, irides and crystalline lens; posterior segment examination of vitreous, optic nerve, macula, retinal vessels and retinal periphery, by indirect ophthalmoscope BIO and slit lamp BIO

Refraction is customarily billed separately when done (and excluded from covered services by many carriers except post-cartaract).

Billing for extended retinoscopy with detailed drawings is also billed separately when done but is commonly paid only when a complaint indicates (or not paid even when the complaint dictates, if you have Aetna.)

Static perimetry is not included.
Standard Color plate examination may be included; specialized color vision exam (SPP2, FM30, FM100, etc) is not included in a routine eye examination
Stereopsis testing may be included (Titmus Fly or circles).
Photography is generally not included, including angiography
Ultrasonography is not included
Scanning laser ophthalmoscopy (or scanning laser tomography) is not included
Pachymerty is not included
Gonioscopy is not included
Sensorimotor examination may be billed separately
Surgery or any instrumented treatment (e.g. forceps epliation) is not included

I did not include the required history: cc, current and past history, ROS, FH, occupational history, EtOH, drug, allergies; I am assuming those are collected as well.

Completely agree with this except that our office only charges the refraction fee if the patient is actually given a prescription for glasses.

 

[orbitsurgMD]

You are generous. I think if the work is done, the work is billable. Writing a prescription is separate, and it can be for the manifest, the wearing Rx (if the patient still prefers their glasses to the manifest for some reason) or possibly no prescription if you tell the patient there is no change and they decide not to get glasses. If they change their mind later and want the Rx, you have been paid for the work you did (and for the work you may possibly have to do in an Rx check, if required.)

 

[PBEA]

nice summary, and I agree with the sentiment "if the work is done", if the refraction is performed it is billed. I dont do refraction on most people but when it is done, it is billed.

Is a "routine eye exam" a service that should be provided regardless of "current and past history, ROS, FH, occupational history, EtOH, drug, allergies, etc"?

 

[orbitsurgMD]

nice summary, and I agree with the sentiment "if the work is done", if the refraction is performed it is billed. I dont do refraction on most people but when it is done, it is billed.

Is a "routine eye exam" a service that should be provided regardless of "current and past history, ROS, FH, occupational history, EtOH, drug, allergies, etc"?

Not necessarily. That is why there are differing levels of eye codes in the 99xxx and 92xxx ranges. If a complete exam was done recently, then a problem-focused exam involving fewer elements may be reasonable. There should be a complete exam somewhere in record, and usually, but not always the first exam is a complete exam, and depending on the nature of any medical problems, an exam of similar depth should be repeated (not less frequently than once every two years, ordinarily.)

 

[PBEA]

Not necessarily. That is why there are differing levels of eye codes in the 99xxx and 92xxx ranges. If a complete exam was done recently, then a problem-focused exam involving fewer elements may be reasonable. There should be a complete exam somewhere in record, and usually, but not always the first exam is a complete exam, and depending on the nature of any medical problems, an exam of similar depth should be repeated (not less frequently than once every two years, ordinarily.)

Thanks, and I agree with all of the above. I admit I'm being a bit vague with this thread, if only to generate a bit of discussion. My feeling has been that a "routine eye exam" is when a pt presents with:

1) No complaints (including blurred vision, HA, etc)
2) No relevent medical history (DM, HTN, etc)
3) No pertinent physical finding (cataract, glaucoma, dry eye, etc)

anything else is not "routine"

 

[Dusn]

I haven't experienced the world outside of residency yet but I was told that a patient has to have some sort of pathology for insurance/medicare to pay for their visit. I'm assuming that most of the patients that optometrists see have no pathology (especially the younger patients) and are just going for glasses or contact; how do they bill insurance for the visits? Does everyone get a dry eye or mild cataract diagnosis?

 

[Visionary]

I haven't experienced the world outside of residency yet but I was told that a patient has to have some sort of pathology for insurance/medicare to pay for their visit. I'm assuming that most of the patients that optometrists see have no pathology (especially the younger patients) and are just going for glasses or contact; how do they bill insurance for the visits? Does everyone get a dry eye or mild cataract diagnosis?

Now you've gone and done it.

 

[Andrew_Doan]

Completely agree with this except that our office only charges the refraction fee if the patient is actually given a prescription for glasses.

This is our policy too.

 

[Shnurek]

I haven't experienced the world outside of residency yet but I was told that a patient has to have some sort of pathology for insurance/medicare to pay for their visit. I'm assuming that most of the patients that optometrists see have no pathology (especially the younger patients) and are just going for glasses or contact; how do they bill insurance for the visits? Does everyone get a dry eye or mild cataract diagnosis?

Keyword there.

 

[dantt]

I haven't experienced the world outside of residency yet but I was told that a patient has to have some sort of pathology for insurance/medicare to pay for their visit. I'm assuming that most of the patients that optometrists see have no pathology (especially the younger patients) and are just going for glasses or contact; how do they bill insurance for the visits? Does everyone get a dry eye or mild cataract diagnosis?

I've mostly seen optometrists for glasses. Medical insurance does not cover this. However, many people have separate vision plans similar to how they have separate dental plans. These plans typically allot a certain amount of money per year for glasses, contacts, exams, etc. In the absence of needing anything besides glasses, it's usually advantageous to see an optometrist over an ophthalmologist assuming the optometrist charges less.

 

[Visionary]

Completely agree with this except that our office only charges the refraction fee if the patient is actually given a prescription for glasses.

We don't charge if there has been no change in the Rx, because it doesn't take much to figure that out. If the patient will be having surgery (cataracts, LASIK), we also don't charge. Everyone else is charged. I've noticed that some patients will act like they don't want the Rx, then ask for it later. Hard to go back and charge them at a later date. We explain the policy beforehand. Haven't had problems with it.

 

[PBEA]

I haven't experienced the world outside of residency yet but I was told that a patient has to have some sort of pathology for insurance/medicare to pay for their visit. I'm assuming that most of the patients that optometrists see have no pathology (especially the younger patients) and are just going for glasses or contact; how do they bill insurance for the visits? Does everyone get a dry eye or mild cataract diagnosis?

its a fair question, and pretty much cuts right to the heart of why I started this thread. I think there is difference of opinion, among doctors, patients, etc, about what is routine vs non-routine eye exam. While ophtho typically will see a higher load of path, ODs also see a fair share, so it is misleading to say that ODs just see normals. In fact, it is exactly that assumption that is misleading. As an example if a pt presents to an OD with "blurred vision" are we to presume that it is just a change in refraction? that vs the pt who presents to the ophtho with the same complaint? IMO, blurred vision is more often not a primary refractive problem but instead something like "dry eye or mild cataract".

Whats more is the public perception that they determine the nature of their visit. When that has little if anything to do with whether they are "routine" or not. Is a pt who is "just going for glasses or contacts" but has cataract, retinal problems, headaches, etc truly "routine"? Not IMHO.

 

[PBEA]

I've mostly seen optometrists for glasses. Medical insurance does not cover this. However, many people have separate vision plans similar to how they have separate dental plans. These plans typically allot a certain amount of money per year for glasses, contacts, exams, etc. In the absence of needing anything besides glasses, it's usually advantageous to see an optometrist over an ophthalmologist assuming the optometrist charges less.

That one part is not always accurate, some medical insurances do cover routine exams and glasses, not carved out through a vision plan but as a benefit paid by their medical plan. Personally I think this type of coverage is easier to deal with. For example a very common occurence is for someone to come in to "check their eyeglasses", when in fact they have multiple eye problems, none of which revolve around the need for new glasses. Being in network for both allows the OD/MD to deliver care without necessarily referring to an in network provider. Less delay, less fragmentation of care, less hassle for doctor and patient, and lower costs.

 

[Tippytoe]

If there is any equity in eye care, it's the billing between ODs and ophthalmologists. ODs can and do bill the same medical and vision codes as ophthalmologists (short of the major surgical procedures, of course). We bill 99xxx and 92xxx.

The trick comes into play when a patient has both BCBS (medical) and VSP or Eye Med or some other vision insurance and they have a refractive change of -0.50 OU with a grade 1 cataract. Is this refractive and should it go to her VSP or is it medical and should go with her BCBS?

We fight this almost daily. Medical usually has a higher copay so of course, the patient wants us to bill the one that will cost them the least (usually the vision plan---which also pays the doc less).

And for the record, my days are filled with routine exams, glaucoma/IOP checks, cataract diagnosis/post op care, allergic/bacterial conjunctivitis, corneal/conjuntival foreign bodies, contact lens fits, K-cone fits, random eye pain, visual field loss (CVA), cornea dystrophy/degeneration. Doing pachymetry, OCTs, B-scans, corneal topography, Visual fields, retinal photos, anterior segment photos. Maybe order a few CT/MRIs per month. Oh yea, lots of dry eyes and blepharitis.

But for most of the unwashed masses: Blurry vision means = the glasses needing more medicine and nothing you tell them will change their mind. So they demand a refund from you and head off to the next eye doc that can make those magical glasses for them (the ones that will work through diabetic retinopathy and cataracts and macula degeneration). I actually keep a list of the few local OMDs and ODs that I don't like so I can send them these patients.

The goal is the same for all of us--- to get them to see as well as possible with glasses or contact lenses or surgery. If surgery won't help (advanced ARMD, for example) I just continue to see them till the end.

I usually don't involve a surgeon unless surgery is needed.

 

[Dusn]

Yeah, I'm not trying to start another optom vs ophtho flame war; I've actually been curious about this for awhile. Since optoms and ophthalmologists use the same billing codes why do ophthalmologists seem to make significantly more in general? Part of this is probably from surgeries but I doubt most of the salary difference can be chalked up to surgeries unless the ophthalmologist is a high volume surgeon with a lot of premium IOLs/LASIK. Many ophthalmologists I know say they lose money by going to the OR.

 

[Visionary]

And for the record, my days are filled with routine exams, glaucoma/IOP checks, cataract diagnosis/post op care, allergic/bacterial conjunctivitis, corneal/conjuntival foreign bodies, contact lens fits, K-cone fits, random eye pain, visual field loss (CVA), cornea dystrophy/degeneration. Doing pachymetry, OCTs, B-scans, corneal topography, Visual fields, retinal photos, anterior segment photos. Maybe order a few CT/MRIs per month. Oh yea, lots of dry eyes and blepharitis.

My personal favorite.

 

[PBEA]

Yeah, I'm not trying to start another optom vs ophtho flame war; I've actually been curious about this for awhile. Since optoms and ophthalmologists use the same billing codes why do ophthalmologists seem to make significantly more in general? Part of this is probably from surgeries but I doubt most of the salary difference can be chalked up to surgeries unless the ophthalmologist is a high volume surgeon with a lot of premium IOLs/LASIK. Many ophthalmologists I know say they lose money by going to the OR.

Many? That cant be true, I'm sure there are examples where they could lose money in the OR, but those would seem to be the exception, as surgery is ophtho's bread and butter. As for office time/ancillary testing, etc, thats what pays the bills. Generally speaking ophtho does higher volume, in a shorter time, often by employing support staff. Higher overhead, but also higher fees/revenue.

On the flip side some ODs limit their service, I've seen many mall/corporate ODs decide to only provide refractive type exams, or the OD may have been pigeonholed by their employer. OD fees are often less then medicare allowable (some may not even enroll or have been unable to access medical plans). Some OD fees are so low they are considered a "loss-leader". IMO, I believe some ODs "just dont get it", or some just dont care. They are content, after all ignorance is bliss. Of course some ODs can make as much as lets say a general ophtho through business ownership/partnership, etc, so the above is not always the case.

One other nasty morsel is that in some cases, medical plans pay MDs more dollars for a given code then an OD. I've yet to hear one valid reason for that nonsense. The other day my child went to the pediatrician for a routine physical during which the nurse checked the visual acuity with a paper snellen chart hung on the wall. Thats it, no ophthalmoscope (as if), no other "eye" test, no nuthin. The EOB from the medical plan listed a vision screening code and paid something like $45. Contrast that with what an OD does during a real eye exam and get paid roughly the same is just plain absurd. Needless to say the screening didnt pick up my childs amblyopia (which I discovered after they did their stupid "screening") which is meriodonal as she has 3 dipoters of cylinder in one eye. Shes all better now, no thanks to our kids doctor.

 

[KHE]

The problem is the use of the word "routine." Patients get into the habit of thinking that a routine eye exam is one which occurs on a routine basis. Once a year. Once every two years. Once every 3 months. Whatever.

 

[mydodger]

One other nasty morsel is that in some cases, medical plans pay MDs more dollars for a given code then an OD. I've yet to hear one valid reason for that nonsense.

Because OMDs are better.

 

[PBEA]

thats the ignorance that makes our lobbyists so well paid.....congrats

any comments on what a "routine" eye exam is?

 

[mydodger]

any comments...?

Nana nana boo boo.

 

[Tippytoe]

Yeah, I'm not trying to start another optom vs ophtho flame war; I've actually been curious about this for awhile. Since optoms and ophthalmologists use the same billing codes why do ophthalmologists seem to make significantly more in general? Part of this is probably from surgeries but I doubt most of the salary difference can be chalked up to surgeries unless the ophthalmologist is a high volume surgeon with a lot of premium IOLs/LASIK. Many ophthalmologists I know say they lose money by going to the OR.

Surgery combined with seeing MANY more patients per day. ODs aren't taught to utilize techs to their fullest. Most aren't even busy enough to need techs. OMDs, by default, are sent more referrals by family docs, peds and others. This helps grow the practice quicker and adds to the snowball effect of family members coming. And there are some snotty people that still refuse to see anyone without an MD behind their name. My sister-in-law refuses to see a PA when she goes to her yearly physical even though, in my opinion, she's just as good, if not bettter than her employer MD.

The average OD sees about 10-12 patients per day. The average ophthalmologist sees _____ per day. I don't know. The ones I've been in with (cat/lasik, retina, and glaucoma) were seeing an average of about 40-50 per day. 2 minute visits and the tech finished up and answered all questions. I've never shadowed a general OMD. We have one here but he's mostly ignored and viewed as someone incompetent by both the OD and OMD community.

Patients enjoy more face time with ODs. It might build loyalty but doesn't pay the bills.

But in the end, it's the number of encounters (and procedures/surgeries) that matter. Also matters that you get a good insurance person. Thay can make or break you in private practice. Insurance billing should be a PhD level degree.

Running a successful business is getting harder and harder for sure.

 

[Visionary]

Also matters that you get a good insurance person. Thay can make or break you in private practice. Insurance billing should be a PhD level degree.

Underestimated by most. When I started in this practice, there was a billing person who didn't know you could capture an exam fee on the same day as a procedure (i.e., 25 and 57 mods). She's no longer with us. No telling how much this practice lost out on before I pointed that out.

 

[MR1]

My idea of routine is any exam on a yearly or more basis. The diabetic with no retinopathy. The annual CL check or MRx check. The annual "eye health" check.

Anything where you are following pathology is not routine.

 

[PBEA]

My idea of routine is any exam on a yearly or more basis. The diabetic with no retinopathy. The annual CL check or MRx check. The annual "eye health" check.

Anything where you are following pathology is not routine.

thanks, I've never heard the yearly or more definition, and thats interesting that you list a diabetic w/o retinopathy. I'd argue that any diabetic eye exam isnt routine. I also think its possible to follow some minor path (early cats, mild AMD, etc) once a year w/o it being considered "routine".

 

[orbitsurgMD]

40-50 patients per day requires significant staff support: a large front desk staff, a manager, technicians for intake, workup, special studies, a scribe/data entry person, even patient escorts whose job is to literally move patients. I have seen high volume university glaucoma services that saw 100 patients a day with one senior doc, one fellow and a large squad of technicians. The fellow looked rode hard and put away wet. All that staffing has a self-fulfilling quality to it, being necessary to see a large volume of patients that is itself necessary to pay a large staff.

Average developed ophthalmology practices will see well over 20 patients per day and busy cataract and retina practices over twice that (really high volume actually requires more than one M.D., as in a fellow.) At that rate, there are many things you cannot do, like preoperative counseling and complex evaluations, like neurology and oncology.

 

[Tippytoe]

Underestimated by most. When I started in this practice, there was a billing person who didn't know you could capture an exam fee on the same day as a procedure (i.e., 25 and 57 mods). She's no longer with us. No telling how much this practice lost out on before I pointed that out.

I've heard many stories of insurance persons stealing money, not filing claims (less work for them) and not following up on rejected claims (ploy by insurance companies who deny at random counting on an overworked insurance clerk not paying attention).

I heard from one guy that his insurance person was literally putting the claims in a desk drawer and he wasn't paying enough attention. When she quit, he found them all and, of course, was in quite a bad mood for a while. But he found out where the money was going............found out the hard way.

I am very fortunate that my wife does my billing. She has a vested interest. Insurance is hard and very frustrating. Hours and hours on the phone. Re-filing and re-filing to collect $18. An employee might just give up on the small monies and move on to the easy stuff. But it all adds up.

Just another reason health care is so expensive and needs to be majorly overhauled. (But I don't have the answer).

 

[Zorro12]

Underestimated by most. When I started in this practice, there was a billing person who didn't know you could capture an exam fee on the same day as a procedure (i.e., 25 and 57 mods). She's no longer with us. No telling how much this practice lost out on before I pointed that out.

Make sure you document well, esp. this year. Reportedly, using the 25 and 57 modifiers is high on the CMS "fraud" watch list for this year.

 

[Visionary]

Make sure you document well, esp. this year. Reportedly, using the 25 and 57 modifiers is high on the CMS "fraud" watch list for this year.

This is true, because so many overuse it. Retina docs, in particular, are prone to it. Many will try and capture an exam fee on every injection visit, despite the fact that the injection fee has a built-in limited exam reimbursement. Those docs are just asking to be audited. I am quite conservative in that regard. I only bill the exam on the initial visit and every 4th visit or so. The later visits are usually when I'm looking at the untreated fellow eye or assessing other pathology (e.g., glaucoma, cataracts). If I'm treating both eyes and there is no other pathology, I rarely bill an exam after the first. If I'm audited for that, they'll rue the day, because I'll take them all the way to federal court. Malpractice insurance covers legal counsel for audits, FYI.

 

[Paddington]

Do you guys bill medical insurance or vision insurance?

 

[PBEA]

Do you guys bill medical insurance or vision insurance?

depends on the problem the pt has, some are medical, some are vision