Distinguish between wellness and medical eye exams

September 15, 2020
Eric Botts, OD

Volume 12, Issue 9

Educate patients, provide consistent messages from OD and staff, and get paid for what you do

It is essential to know the differences between routine and medical eye exams, spend time educating patients on these differences and provide consistent messages to patients, know how to ensure insurance reimbursement after submission, and know how to navigate common challenges providers face in different scenarios.

Practicing full-scope optometry includes prescribing glasses and contact lenses as well as diagnosing and treating all ocular disease each OD’s license allows. Receiving reimbursement for every service performed is just as critical to ensure the success of the practice.

Optometrists are ideally positioned to receive reimbursement from both routine vision care plans and medical insurance carriers. ODs know that routine vision care plans typically reimburse at lower fees than medical carriers, and most patients who have routine vision benefits also have medical insurance coverage. Many patients will ask to use their vision benefits for medical care because their out-of-pocket expenses are likely lower with vision benefits.

How often does this scenario occur in your practice, and how do you address it? How often do you provide a medical diagnosis and treatment plan during a routine eye exam? It is imperative that ODs understand the difference between a routine exam and a medical exam so you they accurately reimbursed for every service provide.

Vision wellness versus medical

ODs are guilty of performing a medical eye examination and billing it to the lower-paying vision care plan because, as I see it, they are unwilling to educate their patients on the differences between routine and medical exams. ODs justify this behavior with excuses, but ultimately I have found that it does not always result in better patient care. The best patient care requires excellent clinical skills in addition to the best technology ODs can afford to provide to their patients.

To address this conundrum head on, I suggest ODs first decide what makes up a routine or wellness exam versus a medical eye exam. A routine or wellness eye exam should be focused on establishing an accurate refractive correction for the patient as well as evaluating for the detection of ocular abnormalities. Identifying obvious pathology or active ocular disease is part of the routine exam.

Another factor is what tests are involved in identifying pathology. Occasionally the patient’s routine vision care plan may reimburse for screening tests, so be sure to read all vision care plan contract to establish whether a certain test is a covered service.

Treatment of ocular disease beyond providing refractive correction should be reserved for a medical ocular exam.

Educating patients

Educating the patient on the differences between a routine wellness exam and medical exam requires a concentrated effort to ensure both staff and doctors are relaying the same message to every patient. This begins with training doctors and staff to precisely share with the patient what the vision care plan covers as well as the benefits covered by medical insurance. This may best be accomplished by using a written intake form with clearly defined definitions of routine and medical ocular care.

Upon finding medical conditions or disease during a routine exam, identify them for the patient and offer to have the patient return for follow-up or additional tests at a later date to diagnose and treat the ocular disease.

Chief complaint A medical exam differs from a routine exam in several aspects, including the number of tests performed, level of medical decision-making, and primary diagnosis. One deciding factor to differentiate routine from medical ocular examinations is the chief complaint. In many cases, the chief complaint may easily determine the type of exam to be performed, but for some patient encounters the chief complaint can be similar for both routine and medical ocular exams. A medical ocular examination must include a primary medical diagnosis and treatment plan that addresses the chief complaint. It may also involve monitoring patients with systemic disease and/or taking high-risk medications that can cause ocular disease. Testing It is important to note that when performing a medical ocular exam, perform only the tests determined by medical necessity to diagnose and treat the patient. Medical necessity, as defined by Center for Medicare Services (CMS), means no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Documentation must support the need to order and perform tests that are deemed necessary to diagnose and treat the patient. A common ocular disease seen in most optometric practice is dry eye syndrome. Dry eye disease may result in blurry vision or eye discomfort. It requires proper assessment, provided during a medical office visit (99202-99214 or 92002-92012) in addition to lab tests including tear osmolarity (TearLab, 83861) and MMP-9 (InflammaDry, Quidel; 83516), to accurately diagnose and treat. Provider challenges What if a patient whose medical insurance carrier does not credential ODs for its panel presents with a medical condition? The best way to handle these scenarios begins with having an office policy that addresses the situation and understood by both doctors and staff, so the patient receives a consistent response from everyone in the office. It is up to the OD to determine the policy; however, consistency and transparency help to avoid conflict. It may start with triaging patients when scheduling the appointment by asking why the patient is scheduling the appointment or inquiring if the patient is experiencing symptoms like blurry vision or ocular discomfort. In this scenario, for example, your staff can address the dry eye patient prior to presenting for the appointment that office policy is to submit the initial exam for a patient with ocular disease such as dry eye to the patient’s medical carrier. If the OD is not a provider for the patient’s medical insurance carrier, staff should inform the patient of the out-of-pocket costs or recommend another provider who is in-network for the patient. It remains the OD’s prerogative to perform medical examinations and submit the claim to the patient’s vision care plan using the refractive diagnosis code as the primary code for the exam. However, doing so reduces the value of the OD’s clinical skills utilized to provide full-scope optometric care. Looking ahead In the fast-changing world we practice in today, disruptive technology will continuously be introduced to the profession. If ODs are focused on providing full-scope primary-care optometry to their patients, there should always be a place for them to provide excellent patient care utilizing the best technology they can afford.

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