By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
April 6, 2022
Insurance benefits can sometimes be bundled, and often cannot. Here is when to bundle benefits, and when not to, so patients are helped and the practice is protected.
Within the discussion of coding and billing, what is bundling?
The CPT code definitions define what is bundled (i.e.: included) in the various eye examinations. For example, a visual field test is bundled (included) within the CPT definition of a comprehensive medical eye examination.
Why would someone try to unbundle a procedure from a CPT code? The reason is to charge for them separately and, therefore, receive a higher reimbursement. As an example, you cannot unbundle a visual field test (bundled as part of the comprehensive medical eye examination) so that it can be billed separately. It is forbidden.
But what about refraction? For coding and billing purposes, is it covered within the definition of an eye examination or not? According to the actual CPT code definitions, a refraction is not a covered service covered within any level of the 92000 or 99000 medical eye examinations. The CPT refraction code is a separate service.
Medicaid and vision plans take a different approach. They often bundle the medical eye examination with a refraction.
The best way to know when a code, such as the one for a refraction, is bundled or not and covered or not is to (1) read and understand the coding and billing policies of each and every third-party plan that you sign up to be a provider for and then (2) check your Explanation of Benefits (EOB) to verify what is covered or not.
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A good place to start is the carrier’s Local Carrier Determination (LCD). You should be able to find a link on the carrier’s website. The LCD gives further insight into each code. If there is no LCD for the specific code you are looking for, then the plan will default to the National Carrier Determination (NCD). This requires a lot of work, but it is necessary to both code and bill correctly and to know what your reimbursement should be.
The ideal solution would be if every third party – medical and vision plans – would follow the same rules for coding and billing. (Isn’t that one of the things that HIPAA tried to achieve?) But in today’s world, where each company is trying to brand themselves as different from others, we are stuck with procedures such as refractions sometimes being bundled into an eye examination while other times they are not.
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