How much does an eye exam cost?

[KHE]

Surely they're not really billing all those extended ophth. I think I'd slit my wrists before having anything to do with that audit. Surely, if something was really that awry, they would have been audited already...?

I would bet that the poster's confusion on this stems from the following:

It seems likely that this Lenscrafters is charging extra for pupil dilation and on their billing sheet or receipts, they use the term "extended ophthalmoscopy" and perhaps even list a CPT code for "extended ophthalmoscopy" even though the service that they are providing in these cases is a routine dilation and NOT actually a true extended ophthalmoscopy.

It would be unlikely that they would get paid from major medical insurances for that procedure unless they had appropriate ICD-9 codes linked directly to that procedure. If they are actually getting paid without appropriate diagnoses, then they're really lucky on the one hand but really unlucky on the other because that could seriously come back to haunt them.

There was a time when I worked in a commercial practice that would bill a certain amount for an exam and another amount for the refraction to a few major medicals. The total amount billed was less than what the major medical plan normally reimbursed for a routine vision exam (if the major medical had a yearly routine vision exam benefit) but the entire bill was "paid" under that benefit, giving the illusion that the plan covers refractions when in fact they just lumped the two fees together and paid it.

It seems likely that that or some variation of that is what is happening here, leading the poster to think that the plan is actually paying for extended ophthalmoscopy when it's really not. It's just reimbursing the total amount submitted for the "eye exam."

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Members don't see this ad.

 

[meameame12]

In response to this old post: most EyeMed plans state that dilation IS included with their ridiculously low reimbursement amounts. So most patients will obviously know that you can't get away with charging extra for a dfe. Our office fees are higher, as they are based on location and current market rates. Basic exam is 95, comprehensive is 35 extra. Most patients decline/refuse dilation, and thus the separate fees. Most patients choose to have an optomap instead, which is 35.

I also don't agree with charging LESS for an established patient--does any other doctor charge less just because you've been there before? You're still devoting the same time and using all of your equipment and staff on that patient. Lastly, I also disagree with charging a minor less--again, still the same amount of work, and in most cases, MORE work for kids! (at least more time is involved)

 

[VA Hopeful Dr]

In response to this old post: most EyeMed plans state that dilation IS included with their ridiculously low reimbursement amounts. So most patients will obviously know that you can't get away with charging extra for a dfe. Our office fees are higher, as they are based on location and current market rates. Basic exam is 95, comprehensive is 35 extra. Most patients decline/refuse dilation, and thus the separate fees. Most patients choose to have an optomap instead, which is 35.

I also don't agree with charging LESS for an established patient--does any other doctor charge less just because you've been there before? You're still devoting the same time and using all of your equipment and staff on that patient. Lastly, I also disagree with charging a minor less--again, still the same amount of work, and in most cases, MORE work for kids! (at least more time is involved)

Yes, most of us in fact.

 

[socal2014]

That is quite overwhelming!

Can somebody explain me the basics of these codes?

Who makes the codes?
Why make a code?
It seems highly unprofessional. It seems as if doctors services are treated as products because of the codes.
Do patients know about the code ?
Do doctors get the full amount ?

 

[JMU07]

That is quite overwhelming!

Can somebody explain me the basics of these codes?

Who makes the codes?
Why make a code?
It seems highly unprofessional. It seems as if doctors services are treated as products because of the codes.
Do patients know about the code ?
Do doctors get the full amount ?

I've only had some basic coding and billing, but here you go. You need a code for each procedure in order to file insurance. You can't get paid for a visual field, for example, unless you check the box on the fee sheet that you did it. People who don't have insurance and pay in full for everything don't really need codes. (I think S codes have something to do with this but those really confuse me.) Patients don't know codes, most docs probably don't have all of them memorized either. Think about the last time you saw some kind of doctor, they told you "This is your co-pay, we'll file it with your insurance." No mention of codes because it's not important for you to know. I don't know how much the general public knows about insurance, probably hardly anything. They just know that when they see a doctor someone there is going to file their insurance.

Doctors do NOT generally get the full amount. Give you an example. Say your patient has Insurance X. They will reimburse you $20 for an eye exam. Your patient has a co-pay of $20. That means you're getting paid 40 bucks for that eye exam even if you charge $100. If you have another patient without insurance, they're paying in full so you will charge them $100.

It's way more complicated than that, I'm just giving you a very basic example. I'll let one of the docs here get into the nitty gritty if you're really interested.

 

[socal2014]

Is it the same for other doctors? I.E. MD's, Dents etc.

Insurance companies must be making a lot of money to be honest.

What are the best insurance providers for doctors AND patients?

What do you need to be approved for these "insurance codes"?

thanks.

 

[JMU07]

Is it the same for other doctors? I.E. MD's, Dents etc.

Insurance companies must be making a lot of money to be honest.

What are the best insurance providers for doctors AND patients?

What do you need to be approved for these "insurance codes"?

thanks.

Yes, there are codes for literally every medical procedure. They're called ICD-9 codes (soon ICD-10), you can google or wikipedia it if you want. My mom is a certified medical coder so she knows all about this kind of thing. She makes sure that the docs she works for are coding the correct procedures and that everyone is getting reimbursed and paid. I won't pretend to know the best insurances, because I don't. In order to be approved, you have to be on that insurance company's panel, and I don't know one thing about that. Something else I'll leave to the docs here.

 

[eceyedoc]

Comprehensive $85
Sph fit $80
Toric/mf fit $100
Cl eval (existing pt) $55
Medical $55
Optos $39
All addt'l testing billed at mc levels

Thinking I should probably bill exams at mc level and offer a cash discount...

 

[VA Hopeful Dr]

Comprehensive $85
Sph fit $80
Toric/mf fit $100
Cl eval (existing pt) $55
Medical $55
Optos $39
All addt'l testing billed at mc levels

Thinking I should probably bill exams at mc level and offer a cash discount...

At the very least

 

[PBEA]

Yes, there are codes for literally every medical procedure. They're called ICD-9 codes (soon ICD-10), you can google or wikipedia it if you want. My mom is a certified medical coder so she knows all about this kind of thing. She makes sure that the docs she works for are coding the correct procedures and that everyone is getting reimbursed and paid. I won't pretend to know the best insurances, because I don't. In order to be approved, you have to be on that insurance company's panel, and I don't know one thing about that. Something else I'll leave to the docs here.

not ICD9 (those are diagnosis codes). procedure codes are spelled out in plain english by CPT, read it, learn it, live it. You will want to purchase a CPT book and start right away.

 

[PBEA]

Comprehensive $85
Sph fit $80
Toric/mf fit $100
Cl eval (existing pt) $55
Medical $55
Optos $39
All addt'l testing billed at mc levels

Thinking I should probably bill exams at mc level and offer a cash discount...

this is a very simplified superbill, and is typical of many ODs, especially in the mall. Its a big reason why those ODs often are uncomfortable with the proper use of CPT. Because they don't actually use it, or learn it. I'd suggest buying a CPT book and learning the proper way to code office visits and procedures.

 

[tomc1227]

Hello everyone,

I found this thread through a Google search, and I'm hoping someone can help me. I went to a new optometrist for an initial exam and contact lens fitting. I am a disposable lens wearer (now wearing Night & Day lenses).

My question is the price that I've been charged for the new patient contact exam + fitting:

• Exam: $290 ($100 paid by my insurance)
• Fitting: $127

I had a total of two visits -- the initial exam, plus one follow up after wearing my new lenses for a week or two.

I need a sanity check here: is $417 outrageous? It sure seems like it to me. I have yet to pay the $190 for the exam that the office has billed me, and before I do I want to know if I've just been hosed or if this is within reason.

FWIW, I live in the SF Bay Area.

Thanks,

Tom

 

[Meibomian SxN]

Hello everyone,

I found this thread through a Google search, and I'm hoping someone can help me. I went to a new optometrist for an initial exam and contact lens fitting. I am a disposable lens wearer (now wearing Night & Day lenses).

My question is the price that I've been charged for the new patient contact exam + fitting:

• Exam: $290 ($100 paid by my insurance)
• Fitting: $127

I had a total of two visits -- the initial exam, plus one follow up after wearing my new lenses for a week or two.

I need a sanity check here: is $417 outrageous? It sure seems like it to me. I have yet to pay the $190 for the exam that the office has billed me, and before I do I want to know if I've just been hosed or if this is within reason.

FWIW, I live in the SF Bay Area.

Thanks,

Tom

Yes, you got hosed.

 

[VA Hopeful Dr]

Yes, you got hosed.

The fitting fee is quite reasonable. The exam is a little high, but as he/she is in SF I could see that being on the upper end of normal around there.

 

[KHE]

Hello everyone,

I found this thread through a Google search, and I'm hoping someone can help me. I went to a new optometrist for an initial exam and contact lens fitting. I am a disposable lens wearer (now wearing Night & Day lenses).

My question is the price that I've been charged for the new patient contact exam + fitting:

• Exam: $290 ($100 paid by my insurance)
• Fitting: $127

I had a total of two visits -- the initial exam, plus one follow up after wearing my new lenses for a week or two.

I need a sanity check here: is $417 outrageous? It sure seems like it to me. I have yet to pay the $190 for the exam that the office has billed me, and before I do I want to know if I've just been hosed or if this is within reason.

FWIW, I live in the SF Bay Area.

Thanks,

Tom

If the doctor you saw was a participating provider for your insurance plan, they should not be billing you the difference between what they charge and what the insurance company pays for the exam. If you used a non participating provider, you would be responsible for the difference.

As far as contact lens fittings go, those are almost never covered by medical plans so the patient is responsible for the entire fee.

In my office, I charge $150 for the most basic type of contact lens fitting though that includes technician time to teach insertion and removal and lens care techniques. If you are already a previous wearer and were in my office, I likely would not have charged you the full $150.

If your fitting is complicated in any way, my fee is much higher.

So on the contact fitting, I don't think you got hosed. On the exam, $290 seems a bit on the high side. Check to see if you used a participating provider.

 

[Meibomian SxN]

The fitting fee is quite reasonable. The exam is a little high, but as he/she is in SF I could see that being on the upper end of normal around there.

Yes the contact lens exam was reasonable, but $400 for an eye exam? Assuming this patient used their medical insurance for the eye exam, it should have been fully covered; save the $40 office visit copay.

I would take the bill in to the office and ask for an explanation for the charges.

 

[VA Hopeful Dr]

Yes the contact lens exam was reasonable, but $400 for an eye exam? Assuming this patient used their medical insurance for the eye exam, it should have been fully covered; save the $40 office visit copay.

I would take the bill in to the office and ask for an explanation for the charges.

I can guarantee it wasn't insurance, otherwise, even with plans that require 100% out of pocket up to a certain point, you still have a max limit. That could change if out of network and then while I might think it is a bit high, there's nothing illegal about it. This is why you ask about fees up front if paying cash or out of network.

 

[Optogal]

Did anyone notice that this thread has 137-thousand views??

It must be being picked up on Google searches because of the topic name.

 

[ptran504]

If the doctor you saw was a participating provider for your insurance plan, they should not be billing you the difference between what they charge and what the insurance company pays for the exam. If you used a non participating provider, you would be responsible for the difference.

As far as contact lens fittings go, those are almost never covered by medical plans so the patient is responsible for the entire fee.

In my office, I charge $150 for the most basic type of contact lens fitting though that includes technician time to teach insertion and removal and lens care techniques. If you are already a previous wearer and were in my office, I likely would not have charged you the full $150.

If your fitting is complicated in any way, my fee is much higher.

So on the contact fitting, I don't think you got hosed. On the exam, $290 seems a bit on the high side. Check to see if you used a participating provider.

How come no one asked what diagnostic test was done on the patient? Everyone is assuming that this is a simple S code exam and the patient was healthy with no medical diagnosis.....

 

[Retinopathy]

How much to fit specialty lenses? Like say... keratoconus?

A staff doc that I spoke with said he will charge $2000 (two thousand dollars) for a cone fit and he is actually getting patients that will pay this. I asked, "How do you get away with doing that?". He says it's not uncommon. Not many ODs like to fit cones, and he fits them with scleral lenses.

 

[dycsjp]

$2000 fit for scleral lenses is actually probably about right... Scleral Lenses are not exactly cheap and i'm sure the cost of lenses are included in the fit...

KC fits for me are $129 not including the cost of lenses. However, every subsequent followup is billed medically w/ applicable copays.

In regards to dilations, I do not charge separate for my dilations. I don't think that's right. Yes, maybe Eyemed is only paying $40-60 for an eye exam, but dilation is included if its warranted. Dilation is included in the codes you bill and thus should not be billed separately. For self paid customers, I use the S codes which are "Routine Eye Exam" codes that include dilation if needed.

I also find it distasteful for an optometrist in previous postings to ridicule and call "mall OD's ignorant".

that's my 2 pennies for the day :-D

 

[PBEA]

$2000 fit for scleral lenses is actually probably about right... Scleral Lenses are not exactly cheap and i'm sure the cost of lenses are included in the fit...

KC fits for me are $129 not including the cost of lenses. However, every subsequent followup is billed medically w/ applicable copays.

In regards to dilations, I do not charge separate for my dilations. I don't think that's right. Yes, maybe Eyemed is only paying $40-60 for an eye exam, but dilation is included if its warranted. Dilation is included in the codes you bill and thus should not be billed separately. For self paid customers, I use the S codes which are "Routine Eye Exam" codes that include dilation if needed.

I also find it distasteful for an optometrist in previous postings to ridicule and call "mall OD's ignorant".

that's my 2 pennies for the day :-D

If a dilation is needed that usually means it is not a routine exam and the office visit should not be billed to the eyeglass plan.

Scodes have no definition and do not include "dilation if needed". Again, generally speaking if a dilation is needed it is not routine and is likely going to have extended ophthalmoscopy as a separate fee.

If you perform dilation on normals as part of a routine service then I agree I would not charge separately, but again if dilation is indicated (ex, diabetes, floaters, reduced bcva, etc) then the entire encounter is not routine and should not be billed to the eyeglass plan.

 

[guttata]

If a dilation is needed that usually means it is not a routine exam and the office visit should not be billed to the eyeglass plan.

Scodes have no definition and do not include "dilation if needed". Again, generally speaking if a dilation is needed it is not routine and is likely going to have extended ophthalmoscopy as a separate fee.

If you perform dilation on normals as part of a routine service then I agree I would not charge separately, but again if dilation is indicated (ex, diabetes, floaters, reduced bcva, etc) then the entire encounter is not routine and should not be billed to the eyeglass plan.

I claim ignorance on the S codes, but they seem to be codes used by BC/BS when there are no national codes. If you are speaking about national codes, I disagree with your interpretation. Unless contraindicated, CPT codes 92004, 92014, 99204, 99205, 99244 and 99245 require dilation. I also disagree with your 'likely' use of extended ophthalmoloscopy (CPT 92225) for anyone you dilate. It is reserved for detailed fundoscopic drawings, beyond a normal fundus exam. If you are using this on all your dilated patients, it will be only a matter of time until you receive an audit.

http://www.healio.com/ophthalmology...56-ada1-4fc6d44c63a7}/extended-ophthalmoscopy

Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy of a comprehensive or intermediate eye exam. It is identified in the CPT as 92225 ("Ophthalmoscopy, extended, with retinal drawing [eg, for retinal detachment, melanoma], with interpretation and report; initial") and 92226 ("subsequent"). The CPT goes on to state, "Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a nonitemized service and is not reported separately."

 

[Tippytoe]

I claim ignorance on the S codes, but they seem to be codes used by BC/BS when there are no national codes. If you are speaking about national codes, I disagree with your interpretation. Unless contraindicated, CPT codes 92004, 92014, 99204, 99205, 99244 and 99245 require dilation. I also disagree with your 'likely' use of extended ophthalmoloscopy (CPT 92225) for anyone you dilate. It is reserved for detailed fundoscopic drawings, beyond a normal fundus exam. If you are using this on all your dilated patients, it will be only a matter of time until you receive an audit.

http://www.healio.com/ophthalmology/practice-management/news/online/%7B5d524d73-3c6c-4356-ada1-4fc6d44c63a7%7D/extended-ophthalmoscopy

Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy of a comprehensive or intermediate eye exam. It is identified in the CPT as 92225 ("Ophthalmoscopy, extended, with retinal drawing [eg, for retinal detachment, melanoma], with interpretation and report; initial") and 92226 ("subsequent"). The CPT goes on to state, "Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a nonitemized service and is not reported separately."

I agree. A routine eye exam does absolutely include dilation per most every expert and most every Medicare carrier. Without it is akin to a dentist only looking at your front teeth and saying everything is fine.

If you are not doing dilated retinal exams routinely, you are below the standard of care. Ext Ophthalmoscopy is rarely a legit code beyond a retinal doc. The reimbursement (like $17) is not even worth the trouble of color-coding, labeling and drawing to scale when a photo typically documents much better and pays much better (unless it's something far in the periphery).

But hey, you can bill whatever you want as long as you are willing to take the chance. But if you are an outlier, you will stand out and be investigated. I know of two docs that have been audited (one for doing punctal plugs on like every 3rd pt and one for billing photos on every single pt with insurance {with no retinal findings} ).

 

[PBEA]

I claim ignorance on the S codes, but they seem to be codes used by BC/BS when there are no national codes. If you are speaking about national codes, I disagree with your interpretation. Unless contraindicated, CPT codes 92004, 92014, 99204, 99205, 99244 and 99245 require dilation. I also disagree with your 'likely' use of extended ophthalmoloscopy (CPT 92225) for anyone you dilate. It is reserved for detailed fundoscopic drawings, beyond a normal fundus exam. If you are using this on all your dilated patients, it will be only a matter of time until you receive an audit.

http://www.healio.com/ophthalmology...56-ada1-4fc6d44c63a7}/extended-ophthalmoscopy

Extended ophthalmoscopy is a detailed examination and drawing of the fundus that goes beyond the standard funduscopy of a comprehensive or intermediate eye exam. It is identified in the CPT as 92225 (“Ophthalmoscopy, extended, with retinal drawing [eg, for retinal detachment, melanoma], with interpretation and report; initial”) and 92226 (“subsequent”). The CPT goes on to state, “Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a nonitemized service and is not reported separately.”

yes dilation is included in those codes....but it is not required to bill them. I do realize however that this can vary regionally and by policy or LCD that some medicare carriers or other insurers require dilation to bill comprehensive as opposed to intermediate. Unless it has changed recently ,which I doubt, NGS medicare does not require it (my carrier). Frankly requiring dilation for billing that level of care is stupid IMO, and I'm glad NGS does not require it.

As well I agree with your definition of EO and I made that comment in the context of an "indicated" case. Which I interpret as "likely" having some post segment finding requiring proper documentation. It was not meant to signal billing EO en masse for every pt dilated. Either it is indicated and actually has a condition worth documenting (and subsequently billed) or it does not and is not billed. Having been audited repeatedly I have no problem making that claim.

 

[PBEA]

I agree. A routine eye exam does absolutely include dilation per most every expert and most every Medicare carrier. Without it is akin to a dentist only looking at your front teeth and saying everything is fine.

If you are not doing dilated retinal exams routinely, you are below the standard of care. Ext Ophthalmoscopy is rarely a legit code beyond a retinal doc. The reimbursement (like $17) is not even worth the trouble of color-coding, labeling and drawing to scale when a photo typically documents much better and pays much better (unless it's something far in the periphery).

But hey, you can bill whatever you want as long as you are willing to take the chance. But if you are an outlier, you will stand out and be investigated. I know of two docs that have been audited (one for doing punctal plugs on alike every 3rd pt and one for billing photos on every single pt with insurance {with no retinal findings} ).

I disagree with pretty much your entire post

 

[Tippytoe]

double post

 

[Tippytoe]

I disagree with pretty much your entire post

Okay, so you disagree that it is important to look at the peripheral retina. WOW.

So you work at Wal-Mart or Americas Best, I'd have to assume. Which one so we'll know never to go.


MEDICARE:
"Comprehensive level of service requires an evaluation of the complete visual system. ......... It often includes, as indicated, biomicroscopy examination with cycloplegia or mydriasis and tonometry. It always includes a fundus examination through a dilated pupil, except when medically contraindicated, and initiation of diagnostic and treatment programs". http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2941 Medicare carrier

I don't have time to find the link, but I know VSP spells out specifically that dilated eye exam is mandatory. You can do an s-code for Medicare or anyone else (that means the pt has to pay out of pocket which rarely works for those with insurance coverage) but you are still practicing below the standard of care if not dilating the eyes (especially in older people).

Sorry, but I don't believe you will find many docs that will support your side.

 

[PBEA]

Okay, so you disagree that it is important to look at the peripheral retina. WOW.

So you work at Wal-Mart or Americas Best, I'd have to assume. Which one so we'll know never to go.


MEDICARE:
"Comprehensive level of service requires an evaluation of the complete visual system. ......... It often includes, as indicated, biomicroscopy examination with cycloplegia or mydriasis and tonometry. It always includes a fundus examination through a dilated pupil, except when medically contraindicated, and initiation of diagnostic and treatment programs". http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2941 Medicare carrier

I don't have time to find the link, but I know VSP spells out specifically that dilated eye exam is mandatory. You can do an s-code for Medicare or anyone else (that means the pt has to pay out of pocket which rarely works for those with insurance coverage) but you are still practicing below the standard of care if not dilating the eyes (especially in older people).

Sorry, but I don't believe you will find many docs that will support your side.

sigh, of course I dilate my pts, we are talking about BILLING

I already mentioned variance amongst carriers, obviously trailblazer requires it, as well as some others Im sure. But not all of them require it and that is actually consistent with the ORIGINAL CPT definition. Whereas carriers like trailblazer have modified the orginal CPT definition to suit their reimbursement philosophy.

here's a brownlow quote

"According to CPT, a comprehensive ophthalmological service "often includes" examination with dilation, therefore dilation is not necessarily required to bill 92004 or 92014. But some payers and state specific guidelines may have their own dilation requirements. For instance, according to Trailblazer, the 92004/92014 exams should be done under dilation unless "medically contraindicated. Check with your carrier if you get a denial you think is unfounded. "

As for VSP you are wrong. period

 

[Tippytoe]

As for VSP you are wrong. period

Hmmmm...........this guy would disagree (from another forum) :

I know dilation is required because I was audited after my 3 year anniversary with VSP. They specifically stated that a 92004 or 92014 MUST have a DFE UNLESS you have a good reason not to do it (ie. px refuses, px is pregnant, etc.)

They also specifically stated that if a DFE is not done and there is no good reason for it not being done documented in the chart, that they will downgrade all 92014 and 92004 to the "more appropriate" 92002 or 92012 and require me to refund them the difference.
_______________
I know for a fact that my VSP agreement said a comprehensive eye exam includes dilation unless contraindicated. Maybe there are different VSP contracts in each state. I don't know.

Back to Extended ophthalmoscopy, I found this article which also debukes you:

Extended ophthalmoscopy continues to be among the most heavily audited codes in ophthalmology — and with good reason. From my experience, there are very few audits that I conduct on retinal practices where the parameters for documentation guidelines and compliance are in order when billing this physician service.
http://www.retinalphysician.com/articleviewer.aspx?articleid=101305




"What justifies reimbursement for this test? Most Medicare carriers have published local medical review policies (LMRPs), which include a unique list of diagnoses that justify extended ophthalmoscopy. Some common examples include:

• endophthalmitis
• retinal and choroidal disorders, including neoplasms
• optic disc disorders.

Note that extended ophthalmoscopy is reserved for serious retinal pathology. The procedure should not be billed if you report no findings." http://www.ophthalmologymanagement.com/articleviewer.aspx?articleid=85509

The key is SERIOUS RETINAL PATHOLOGY. I doubt in your commerical cubie your see much serious retinal pathology. You'd be better off just taking a photo of it if you have room in your closet for a camera and you optical master will allow. Common sense says ext opt should be reserved for far peripheral problems that can't be photographed, viewed easily OR for retinal surgical documentation.

But...........I don't care what you do. Just hate to see false info spread around.

 

[PBEA]

Hmmmm...........this guy would disagree (from another forum) :

I know dilation is required because I was audited after my 3 year anniversary with VSP. They specifically stated that a 92004 or 92014 MUST have a DFE UNLESS you have a good reason not to do it (ie. px refuses, px is pregnant, etc.)

They also specifically stated that if a DFE is not done and there is no good reason for it not being done documented in the chart, that they will downgrade all 92014 and 92004 to the "more appropriate" 92002 or 92012 and require me to refund them the difference.
_______________
I know for a fact that my VSP agreement said a comprehensive eye exam includes dilation unless contraindicated. Maybe there are different VSP contracts in each state. I don't know.

Back to Extended ophthalmoscopy, I found this article which also debukes you:

Extended ophthalmoscopy continues to be among the most heavily audited codes in ophthalmology — and with good reason. From my experience, there are very few audits that I conduct on retinal practices where the parameters for documentation guidelines and compliance are in order when billing this physician service.
http://www.retinalphysician.com/articleviewer.aspx?articleid=101305




"What justifies reimbursement for this test? Most Medicare carriers have published local medical review policies (LMRPs), which include a unique list of diagnoses that justify extended ophthalmoscopy. Some common examples include:

• endophthalmitis
• retinal and choroidal disorders, including neoplasms
• optic disc disorders.

Note that extended ophthalmoscopy is reserved for serious retinal pathology. The procedure should not be billed if you report no findings." http://www.ophthalmologymanagement.com/articleviewer.aspx?articleid=85509

The key is SERIOUS RETINAL PATHOLOGY. I doubt in your commerical cubie your see much serious retinal pathology. You'd be better off just taking a photo of it if you have room in your closet for a camera and you optical master will allow. Common sense says ext opt should be reserved for far peripheral problems that can't be photographed, viewed easily OR for retinal surgical documentation.

But...........I don't care what you do. Just hate to see false info spread around.

Yes, that definition for EO is accurate, and I do generally reserve it for peripheral problems, like holes, tears, etc, but if I dont have time for a fundus photo and I need to do a post exam anyway then sometimes I'll bill the lesser EO fee, just to save time.

Look I'm not sure why you want to go 10 rounds with me on this. I've been audited by medicare, and every major medical carrier in the northeast. I'm very comfortable with CPT and how it needs to be done. I regularly bill for OCT, topo, fundus photo, HVF, gonio, etc, etc. For you it almost sounds like you are learning this stuff as you post it, so why not just cut the crap? No need to go into attack mode just cause you don't know everything there is to know about CPT, I'm pretty sure nobody does as it varies quite a bit. Take a deep breath....exhale. Feel better?

I'm in PP for the last 10 years