Coding and Billing

How to Coordinate Medical and Vision Plan Billing

By Tamara Kuhlmann, OD, FAAO, MS

Training staff to code accurately for insurance reimbursement is critical to a practice’s success with medical eyecare services.

Optometry as a profession is advancing in the medical model, and, as optometrists, we need to keep our skills current for the good of our patients and our profession. It also makes good business sense to understand the importance of proper coding and billing.

Understand Difference Between VisionInsurance Plansand Medical Insurance Plans
With the current healthcare reforms pending, the confusion between vision insurance plans vs. medical insurance plans has left optometrists in a unique billing situation not encountered by other professions. The closest analogous situation would be dentistry. Optometrists need to understand the advantages of having the two insurance options available to them for billing purposes, and when appropriate, how to properly implement a strategy to include both medical and vision plans to the patient’s and the practitioner’s best advantage.

First and foremost, the patient’s chief complaint must drive the reason for the visit. To bill medical insurance as primary, the chief complaint must be medical. Having said that, proper documentation of the patient’s medical condition(s), related eye symptoms, and high-risk medications can and should all be recorded in the presenting reasons for the patient’s visit. Next, proper objective testing with documentation and reporting is standard of care. Lastly, patient communication of the treatment plan, proper diagnostic and billing coding completes the SOAP format optometrists are trained to do.

Explain Insurance to Patients
If the patient had a medically related chief complaint or presenting illness and a primary medical diagnosis is documented such as diabetes, cataract, macular degeneration, EBMD or K. Sicca, the visit can be billed to the medical carrier as the primary insurance. If the patient also has VSP and is eligible for an exam through VSP, VSP may be billed as the secondary carrier. It is extremely important that the doctor explain this strategy to the patient in the exam room before the patient is escorted to the front desk for check out. I suggest the doctor say something like: “Ms. Jones, since you have a medical condition that needs proper professional monitoring and care, your charges today should be filed with your medical carrier first, and VSP as secondary. It is a great advantage to you that you have two insurances we can use for your services today.” Most patients will be satisfied with this arrangement, and they can still enjoy their eyeglasses and contact lens benefits through VSP immediately. Simply create a separate claim for the materials to VSP, and bill the non-covered portion of the exam to VSP later as outlined below.

Coordinate Patients’ Benefits
Coordinating benefits for medical exams between patients’ primary medical insurances and their routine carriers not only benefits patients, but it also allows doctors to be more fairly reimbursed for their services. If the doctor is doing a medical eye exam, the reimbursement should reflect this as well. Medical reimbursements pay more than routine benefits because of the higher level of care, decision-making, risk and expertise.

There are some billing rules that need to be followed when coordinating benefits.

Only exams that include a refraction can be coordinated with the patient’s routine carrier.Refractions are always considered routine in nature, and it is the refraction that allows the coordination between medical and routine insurances.

If the patient is getting eyeglasses or contacts, it is recommended to create two separate claims:one for the exam to file with medical insurance (which you’ll coordinate with VSP later) and one for the hardware that will be billed to VSP immediately. The patient may be responsible for a co-pay, and your office may collect the lower co-pay of the two insurances in order to be patient friendly. Also, there can be instances in which 100 percentof the exam will be covered and the patient has no co-pay.

The exam record must reflect the medical care that was provided, including evaluations, findings, patient communications and treatment plan. If the exam is primarily centered around refractive status and prescriptive options, it was not medical in nature, even if the patient has a medical condition, and cannot be billed medical. In other words, if the patient’s chief complaint is vision related, such as the patient needs new eyeglasses and the patient also has a medical condition that is not causing eye related symptoms, the claim should be billed to VSP.The claim should include the vision diagnosis as primary and the medical diagnosis as secondary. By submitting VSP claims with patient conditions, you are helping facilitate medical care for that patient. In addition, the doctor should communicate with thepatient’s primary care physician (PCP), and educate the patient about his/her condition(s). This will help VSP demonstrate the important role the eye doctor plays in managing vision as well as medical conditions.

Implement Strategy to Coordinate Benefits
To implement this medical/vision plan billing strategy, bill the exam and refraction to the medical carrier first, and since the chief complaint is medical, list the medical diagnosis first. Point the refraction to a routine (refractive) diagnosis so you can bill VSP later as secondary once the medical claim processes. After the payment comes from medical, post the payments and write-offs per the medical carrier’s EOP (explanation of payment). If there is any remaining balance or if the patient had a co-pay, send a paper copy of the claim (CMS-1500) to VSP as secondary. Attach the primary medical EOP form to this claim along with any remark codes that are applicable. There must be a valid VSP exam authorization number. In box 19 of the claim, write “Coordination of Benefits. See primary EOP.” VSP will then pay up to their usual maximum toward the remaining balance not covered by the medical carrier, which typically includes the refraction and part of the patient’s co-pay, since the medical co-pay is typically higher than the VSP co-pay. Remember; when you receive VSP’s payment as secondary, you will not be taking any further write off on the exam.Per coordination rules, you are only obligated to take the medical carrier’s write off.If there is any balance remaining after VSP pays, it is the patient’s responsibility.

You cannot submit just the refraction to VSP while sending only the exam code to the medical carrier. The 92- or 99- code you use for the exam AND the 92015 code for refraction must be submitted to medical first, then the entire EOP and a paper copy of the original claim that was submitted to the medical carrier is sent to VSP for secondary payment.

Coordinating benefits will use up the patient’s VSP eligibility, no matter how small the amount billed. Occasionally, a patient may not benefit by primary-secondary billing if he/she has a high deductible, or if he/she has an HSA or FSA arrangement that could mean more out-of-pocket costs for the patient. The doctor and staff should be sensitive to his situation, but the office cannot have a blanket policy to write off medical co-pays or file VSP as primary routine if the medical charges are applied to the deductible.

For more information, please refer to the VSP website, From the home page, go to VSPOnline, click on “Manuals” to the far left, choose VSP, then choose the “COB Between Health Plans and VSP Plans,” updated 3/21/11. (Make sure to allow pop-ups on your computer.)

By implementing this medical/vision billing strategy properly, patients will get more appropriate care, optometrists can help the patients become better educated about the medical care provided by our profession, and optometrists can get paid more appropriately for their services.
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Tamara Kuhlmann, OD, FAAO, MS,
of Eye Care Professionals in Powell, Ohio, specializes in specialty contact lens studies and disease evaluation and treatment. To contact her:

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