Medical vs. Vision Billing in Optometry: Which Plan Do You Bill?

One of the most common questions we hear from optometry practices is simple: should this exam go to the vision plan or the medical insurance? Getting it wrong leads to denials, refunds and frustrated patients. Here is how to think it through.

Vision vs. Medical Optometry Billing

• Vision plans (such as VSP, EyeMed, Davis Vision and Spectera) cover routine eye exams and eyewear. The visit is about checking vision and updating a prescription.

• Medical insurance (including Medicare and commercial medical plans) covers eye care for a medical complaint or condition, such as red eye, flashes and floaters, dry eye, diabetes, glaucoma or cataracts.

  
  

The reason for the visit usually decides which plan to bill - vision vs. medical. If the patient comes in for a routine check and new glasses, it is generally a vision plan visit. If they come in with a symptom or for monitoring of a medical condition, it is generally a medical visit. This is where Medical vs Vision billing comes into play.

Start with the Chief Complaint

The patient's chief complaint and the diagnosis you document drive the claim. Train your front desk to ask why the patient is coming in when they schedule, and make sure the doctor's documentation clearly supports the reason for the visit. A routine visit can turn medical when the doctor finds something, so the final decision should be based on what was actually done and documented.

Eye Codes vs. E/M Codes

For medical eye exams, optometrists can bill either the general ophthalmological codes or evaluation and management (E/M) codes:

• Eye codes: 92002 and 92004 for new patients, 92012 and 92014 for established patients.

• E/M codes: 99202 to 99205 for new patients, 99212 to 99215 for established patients.

  
  

Choose the code that best matches the documentation and the payer's rules. Some vision plans also ask for their own routine exam codes, such as S0620 and S0621, so check each plan's billing manual.

Don't forget the Refraction

Refraction (92015) is billed separately from the exam. Medicare does not cover it, and many medical plans don't either, so it is often the patient's responsibility on a medical visit. Let patients know before the exam so the charge is not a surprise.

Verify before the Visit

Checking both vision and medical benefits before the appointment prevents most of these problems. It tells you what the patient's plans cover, whether a referral or authorization is needed, and what the patient may owe.

When in doubt, Ask

Payer rules change often, and they vary by plan and by state. If your team is unsure how to bill a visit, it is worth getting a second set of eyes before the claim goes out.

Not sure where your practice stands? Take our free optometry billing assessment or see how our optometry billing services work.