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Ask the Codeheads: Eye exams: Medical? Non-medical? ‘Routine’?

November 1, 2012

Edited by Chuck Brownlow, O.D., Medical Records consultant, AOAExcel

Providing eye care is unique in many ways. The “unique-est” of all may be the use of the term “routine eye examinations.” In most contexts, “routine” would convey the notion that the examination is not medical, yet the education of optometrists and ophthalmologists, as well as state practice acts for ODs and MDs, pretty much requires that each examination includes diagnosing or ruling out the presence of medical conditions. In other words, there really never is a “routine” eye examination.

No eye doctor can spend time with a patient without considering the health of that person’s eyes. Even if the patient had been seen within the past 24 hours, the doctor will be observing, examining, and probably conducting several tests to assess the eye health and general health of the patient. After all, eye care is at its base health care.

Having looked at thousands of patient records created by hundreds of eye doctors, I have noticed some definite trends.

First, a record for an eye examination will have many of the same characteristics whether the examination was prompted by a medical reason, a refractive reason, or no reason at all. “It’s just time for an eye examination.” As eye doctors, we all understand that.

Each time we see a patient it is important for them and for us that we do certain things to be sure we’re not missing a hidden eye problem or a hidden systemic health issue. This may be a little different from medical records created by a family physician seeing a patient, but in eye care there are great similarities from one record to another, regardless of the reason for the visit.

Second, eye doctors tend to be very thorough in their data gathering, both in the case history and in their examination of the patient. An outsider might think that some of this is excessive and not directly related to the patient’s reason for visit. An outsider, such as an auditor, might remark, “It’s unusual to see such a detailed medical record for a patient with such a limited reason for visit.” Auditors may not know that the health of the eyes is integral to the health of other organ systems and that signs of medical conditions elsewhere in the body will often show up first in the eyes. Auditors may not know that, but we do. Indeed, that is why our examinations and our records are as thorough as they are.

So, if the case history, examination, and medical decision-making are pretty much the same across many patients we see each day, how should we determine where the claim should be sent? How should we decide whether a visit was “medical,” “non-medical,” or “routine”? First, in my book, an optometrist never does a “routine” examination. We are concerned about every patient’s eye health and general health every time we see them, so we can scratch the term “routine” from our vocabulary, leaving just two classes of visits to sort out, “medical” or “non-medical.”

In a practical sense, terminology is not important, as we customize the care we provide to the needs of the patient for each visit. Often, some of what we do in a visit is non-medical, but vision-related, and some is medical. Actually, the only reason we have to classify a visit at all is to determine who gets the bill. The way we do that is by going back to the beginning of the medical record and looking at the reason for the visit. The reason for a visit is the only real determinant of what we do during each patient visit and whether a visit is non-medical or medical.

Medicare’s Carrier’s Manual explains this clearly. It states:

“The coverage of services rendered by an ophthalmologist (or optometrist) is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to an ophthalmologist (or optometrist) with a complaint or symptoms of an eye disease or injury, the ophthalmologist’s (or optometrist’s) services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist (or optometrist) for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.

“In the absence of evidence to the contrary, the carrier may assume that an eye examination performed by an ophthalmologist (or optometrist) on the basis of a complaint by the beneficiary or symptoms of an eye disease was not for the purpose of prescribing, fitting, or changing eyeglasses.”

Note: “or optometrist” and “or optometrist’s” terms were added to the original language by the author of this article, but can be assumed to have been the intent of the policy’s original drafters.

My suggestion is that you create policy within your office to reflect long-standing logic, the rules of Medicare, and the language of many insurers’ provider agreements. If the patient enters the office for a medical reason, presenting problem, symptom, or complaint, the care provided is considered medical and will be billed to the patient and the patient’s medical insurer. If the patient enters the office for a non-medical reason, without a medical problem, symptom, or complaint, the care is considered non-medical and is billed to the patient and/or the patient’s non-medical payer (e.g., vision plan or insurer).

Hopefully, billing decisions for doctors and staff and payment decisions for insurers will be simpler and more consistent if all of us can develop and adhere to firm policy when making these decisions. We’re very good at providing excellent, cost-effective and high-quality health care services in our offices. It’s time we get better at making consistent decisions relative to coding and claims submission.

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