By Mark Wright, OD, FCOVD
and Carole Burns, FCOVD
April 5, 2017
The patient presents in your office with a red eye. The patient has both medical insurance and vision insurance coverage. The medical insurance has a $500 deductible, which has not yet been met. The vision insurance has a $20 co-pay. The patient wants to use the vision insurance for today’s examination because there is only a $20 co-pay. What do you do?
The key to helping the patient navigate the insurance minefield is to understand how a refraction fits into this situation. The CPT medical examination codes (92000 and 99000 codes) do not include a refraction in their definitions. That means if a refraction is done, the medical examination code is billed and the refraction code (92015) is also billed. On the other hand, vision insurance codes for a comprehensive or intermediate code include a refraction, therefore, only the examination code is billed even when both an examination and a refraction are done.
Vision insurance is for “routine” eye examinations. Medical insurance is for situations where there is a medical sign, medical symptom, or ongoing care for a medical condition. Medical insurance does not cover cases where the reason for the examination, or primary diagnosis, is myopia, hyperopia, astigmatism or presbyopia.
Another important difference between medical insurance and vision insurance is how many times each year the coverage can be used. Most vision insurance plans only permit the vision insurance to be used one time per calendar year. It’s also important to note that vision insurance cannot be separated into examination and refraction. The examination and refraction are tied together and can only be used on the same day, once a year. Medical insurance can be used multiple times over the course of the year. The only limiting parameter for medical insurance is medical necessity. Medical necessity opens the gate for medical insurance reimbursement.
In the case above, the patient presents with a red eye. The red eye is a medical sign of an underlying medical condition. This is covered by medical insurance, not vision insurance.
The conversation to have with the patient is to explain that if you use the vision insurance today, it uses the refraction coverage today, then, in one week, when the patient returns to the office, they would have to pay for the examination and for the refraction. This means that they will end up paying more for the two exams.
The best way to approach this case is to do it the way the two insurances have been set up to be used. Use the medical insurance for the first visit because there is a medical reason for the examination, then, when the patient is healed, you can use the vision insurance with its covered refraction. Doing it this way coordinates the patient’s insurance coverage. You are following the insurance rules, and at the same time, minimizing the patient’s total out-of-pocket expenses.