Taking the Confusion out of Routine vs Medical Exams for Optometry Coding

Eye exams are one of those issues that can cause confusion in the billing department. Do you bill the exam as a routine exam or medical exam? Is there a difference? Understanding these basics is essential for your billing department in order to avoid a delay in the processing of your payments. Because many eye exams could fall under both vision and medical insurance, it is essential that the procedures are coded properly to ensure proper payment.

What Makes an Eye Exam Medical?

Seeing the eye doctor can mean that a patient is having difficulty with his/her vision. This would typically lead to a routine exam and be billed to the vision insurance company. Seeing the same doctor for conjunctivitis or any other medical issue that pertains to the eyes would be considered for the medical insurance. Of course, there is always the area in the middle that can shake the balance of whether or not the claim should be a vision or medical claim. In these instances, the chief complaint and medical history will play a role in which insurance is billed.

Filling in the Gray Area

Unfortunately, not all patients are cut and dry for optometry coding. A patient might come into the office for a routine eye exam or claim difficulty with his vision and have no other complaints. Upon completion of the exam, however, you find that he/she has medical issues, such as glaucoma or cataracts. If you ask the patient to come back and see you for a follow up, whether a few weeks or a few months from now, the issue has now turned medical. The initial appointment to determine the level of difficulty that the patient was having with his vision still pertains to vision insurance, but as soon as the appointments are made and focused on a medical issue, medical insurance becomes responsible.

Understanding the differences between vision and medical insurance can be a daunting task for any billing department. Whether you run your own billing or you have a department of employees that handle it for you, extra care needs to be taken to determine which insurance is responsible in order to keep your practice profitable and to avoid having to rebill or go to the patient for lack of payment from the insurance company.

Applied Medical Systems have experts that understand all aspects of optometry coding. We have a full understanding of which codes are considered medical and which are vision related. Our experts have been handling optometric billing services for the last 30 years and it has become second nature for them to understand which insurance company is responsible for the various eye exam related charges to make it easy for optometrists to stay efficient and profitable.

Contact us today for a free consultation with our optometry billing and coding experts.