Written by the AOA’s Coding & Reimbursement Committee.
The U.S. Food and Drug Administration (FDA) recently approved an eye drop for presbyopia (ICD-10-CM code H52.4). Additional medication regimens are currently under development. The AOA Coding and Reimbursement Committee has been asked to recommend the proper coding options when doctors of optometry prescribe eye drops as an adjunctive treatment option for presbyopia. To address this issue, the committee will review several different types of alternatives for billing eye examinations.
Medical insurance (including Medicare) covers the diagnosis and treatment of diseases and disorders of the eye and adnexa. An office visit meets the standard of medical necessity when patients present with chief complaint(s) that are medical in nature and/or for follow up for known medical conditions. Claims for medical visits are typically coded with either the 92000 (General Ophthalmological Services) or the 99000 (Evaluation and Management) CPT® codes. Refractions (CPT 92015) are typically not covered during these medical visits and are the responsibility of the patient (CPT definitions do not include 92015 in the 92000 or 99000 codes).
Well vision benefits typically include an eye-health examination and a refraction to evaluate whether the patient needs visual correction in the form of glasses or contact lenses. Typically, the patient presents with no medical chief complaint(s) or known ocular pathology. The refractive diagnoses for well vision benefits are myopia, presbyopia, hyperopia, astigmatism or emmetropia. Most claims for well vision benefits are coded with the 92000 CPT codes (with or without the refraction code) or HCPCS S0620/S0621 (routine ophthalmological examination including refraction; new patient/established patient codes). Well vision benefit plans often bundle the payment for refraction service into the reimbursement for another service code performed during the same visit. Per HIPAA rules, they are not permitted to state that a refraction service is a component of the General Ophthalmological Service codes or the Evaluation and Management (E&M) codes.
The following scenarios may help with decision regarding coding:
- A patient presents for a refractive or well vision examination and has either well vision benefits or is self-pay for the visit. The chief complaint indicates difficulty seeing at near point. The diagnosis is determined to be presbyopia. The doctor of optometry recommends glasses, contact lenses and/or eye drops for presbyopia. The claim is submitted to the well vision benefits plan or the patient pays for the entire visit. Glasses or contact lenses may be covered for the presbyopia but plan benefits may vary. If the presbyopia eye drops are prescribed, clear documentation that appropriate patient education was given to the patient on the proper use and potential side effects of the drops is advised. Because the treatment plan offered both optical and/or presbyopia eyedrops as reasonable and effective options, the prescription of the presbyopia eyedrops would be considered a part of the treatment plan and no additional charge for the issuance of the prescription would be justified. At this time, there are no known well vision benefits that are covering the eye drops for presbyopia correction.
- A patient presents for a medical visit and also indicates they are having problems seeing at near or even asks about the use of the new eye drops for presbyopia. The doctor of optometry addresses the presenting or existing medical problem(s), documents the findings and the treatment plan and chooses the appropriate examination code. To address the complaint of blurred near vision that has been determined to be nonmedical in nature, if appropriate, the refraction (92015) should be billed to the insurance carrier with the diagnosis of presbyopia (H52.4 ICD-10-CM). The refraction is typically denied by the medical carrier and becomes either the patient’s or existing vision benefit’s responsibility. After the performance and documentation of any additional appropriate testing and patient education on the proper use and potential side effects of the drops, the provider may decide to prescribe drops for presbyopia. If selecting an E&M code on the basis of time, any fee associated with the evaluation and consultation leading to the prescribing of the presbyopia eye drops would be included in the level of E&M code chosen. While the discussion of the management and risks/benefits of the presbyopia drops can be included in time counted toward the E&M visit, the time for the refraction cannot be counted as it is separately billed. When using Medical Decision Making (MDM) for the selection of E&M code, the prescribing of medication may increase the level of MDM for the visit but only because the chief reason for the visit was medical.
- If the doctor decides the prescribing of eye drops for presbyopia warrants a separate office visit to perform a therapeutic trial under supervision or for a follow up once using the medication, careful documentation that these visits would be noncovered services is advised. A signed ABN (Advanced Beneficiary Notice of Noncoverage) or private insurance equivalent is recommended. The claim would be submitted with a GX modifier appended when using the examination code with the presbyopia diagnosis. Providers are advised to avoid the use of any diagnoses codes that do not accurately describe a patient’s condition for presbyopia. A Good Faith Estimate (GFE) of noncovered services might be provided if required to comply with the new No Surprises Act.
- Two other coding options for example No. 3 might be considered. The HCPCS code S9986, defined as a not medically necessary service(patient is aware that service is not medically necessary) could be used. In this scenario, the patient is advised in advance that it will not be a covered charge and if submitted to insurance, the claim would be noncovered and the patient’s responsibility. The use of the unlisted general ophthalmologic code (92499) might also be considered; however, insurance carriers typically require specific documentation be sent to the carrier and would most likely result in the denial of the claim. Again, the use of an ABN or the private insurer equivalent and a GFE should be considered when using either of these coding approaches.
It is the opinion of the committee, and per HIPAA, that only approved CPT and HCPCS codes should be used for provider billing. The AOA Coding and Reimbursement Committee advice is for doctors of optometry to remain consistent in their billing practices and have the same fee schedule for everyone regardless of their insurance coverage.
If your state allows you to dispense medications and prescribe from your office, the patient would be charged your typical fee for the medication. Otherwise, a prescription would be written and filled by the patient’s pharmacy.