Photo credit: Getty Images
Essential dos & don’ts of using S-codes.
By Mark K. Davis, OD
Feb. 21, 2024
As optometry becomes more involved in medical eyecare, routine eyecare is getting pushed to the side. It does not appear as exciting as providing medical eyecare. Medical eyecare makes us feel like “real” doctors.
I myself am guilty of this. I love to see a “red eye” or “foreign body” appointment on the schedule. It’s very satisfying to write a prescription for medication or perform office surgery. Yet, in most practices, a majority of the gross income is still derived from “routine eyecare,” or services not covered by Medicare.
The question is: how do we get paid for our routine eye exams, which usually involve many of the same ophthalmological procedures as the comprehensive medical eye exam for Medicare patients?
A Quick Review of Healthcare Common Procedure Coding System (HCPCS)
The HCPCS is divided into two principal subsystems, referred to as Level I and Level II.
HCPCS Level I is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). CPT is a uniform coding system consisting of descriptive terms and codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. These healthcare professionals use CPT to identify services and procedures for which they bill public or private health insurance programs. CPT codes are republished and updated annually by the AMA.
HCPCS Level II is a standardized coding system that is used primarily to identify drugs, biologicals and non-drug and non-biological items, supplies and services not included in the CPT code set jurisdiction, such as ambulance services and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies and equipment that are not identified by CPT codes, HCPCS Level II codes were established for submitting claims for these items. HCPCS Level II codes are alpha-numeric codes because they consist of a single alphabetical letter (A-V) followed by four numeric digits, while CPT codes primarily are identified using five numeric digits. Click HERE to learn more about that.
If you sell optical goods and bill vision plans, you are probably already familiar with HCPCS II codes. Some more common ones are:
V2531 – contact lens, scleral, gas permeable, per lens
V2020 – standard frame
V2100 – single-vision spherical lenses
Now, Let’s Look at the S-Codes
As you may recall, each CPT code is assigned a maximum allowable charge each year by CMS. If you charge a Medicare patient the maximum allowable for code 92004, you cannot use the same code and have another lesser fee assigned to it. That is illegal. The exception is when you are contractually obligated to use certain codes by a vision plan to be paid for the “routine” eye exam. For example, VSP requires you to bill an ophthalmological code (92004 or 92014) for the eye exam and the refraction code (92015) to be paid for the annual routine comprehensive eye examination.
So, how do we get paid for our routine eye exams? This is where the HCPCS Level II S-codes come in. By definition, HCPCS S- codes report drugs, services and supplies for which national codes do not exist, but are needed to implement policies, programs or support claims processing. They are not payable by Medicare.
In Texas, and possibly other states, ophthalmological S-codes are used by traditional Medicaid to report routine eye examinations and to file for payment.
Here Are the More Common S-Codes for Optometry/Ophthalmology
S0620 – Routine ophthalmological examination including refraction; new patient
S0621 – Routine ophthalmological examination including refraction; established patient
S0800 – Laser in situ keratomileusis (LASIK)
S0810 – Photorefractive keratectomy (PRK)
Of importance, note the S-code includes the refraction. My personal opinion is that the vision plans should use the S-codes and NOT the CPT ophthalmological codes.
Other Articles to Explore
In my former practice, we used the S-codes for patients not having insurance (either medical or a vision plan) that would pay for the eye examination. We were providers for traditional Medicaid and also used the S-code for filing for the routine eye exam. Again, remember you can have only one fee for each code. Therefore, it is advisable to set your routine eye exam fee above what traditional Medicaid pays. In most cases, this is not a problem.
From a practice management standpoint, S-codes are also important for “phone shoppers.” I’m sure your office gets phone calls from individuals during which the first thing they ask is, “How much is your eye exam?” My mother taught me it was impolite to answer a question with a question, but in this case, that is not the best advice.
My staff was trained to ask if the caller had any medical insurance or vision plan that would possibly help pay for the eye examination. Many callers, if they do not have a vision plan, do not know that their medical plan may have a specific benefit for an annual eye examination. After exploring all possibilities of coverage for the eye examination and finding none, the staff member would then quote our fee for the S-code.
According to Paul Simon, the singer, there are “50 Ways to Leave Your Lover”
But only six ways to bill for an eye exam:
92004 – comprehensive ophthalmological examination, new patient
92014 – comprehensive ophthalmological examination, established patient
92002 – intermediate ophthalmological examination, new patient
92012 – intermediate ophthalmological examination, established patient
S0620 – routine ophthalmological examination including refraction; new patient
S0621 – Routine ophthalmological examination including refraction; established patient
In conclusion, by using the S-codes for your routine eye exams, and having a different fee that is comparable to other eyecare providers in your area, you will stay competitive and out of trouble!
Until next time – Happy Coding!
Mark K. Davis, OD, is a Therapeutic Optometrist and Optometric Glaucoma Specialist, Diplomate, American Board of Optometry, Adjunct Assistant Professor, University of Houston College of Optometry and Chief of Optometry, 147th Medical Group. He is Lt Col, Texas Air National Guard, Ellington Field JRB, Houston, Texas. To contact him: mkdavisod@gmail.com
