Why Refraction Billing Keeps Triggering Optometry Claim Denials and How to Finally Stop It
Optometrist billing suffers more financial losses because of refraction billing errors than almost any other billing mistake; and most of these losses remain hidden until the denial report gives away an unpleasant truth that nobody is willing to see.
Ophthalmology Practice Billing Services who specialize in eye care understand the whole chaos pretty well. CPT 92015, the determination of the refractive state code, operates in one of the most difficult billing environments in medicine as a whole.
It is statutorily excluded from the Medicare coverage under Section 1862(a)(7) of the Social Security Act irrespective of whatever the patient's diagnosis may be. Moreover, whenever the code is used inappropriately, like incorrectly included into the claim or sent to a wrong payer or modifier; not only is the payment denied, but the whole claim goes down with it as well.
It is the cascading effect of the process that makes refraction billing crucial. Just one mistake and everything is lost!
Why Does CPT 92015 Get Denied So Often?
The CPT code 92015 (determination of refractive state) is rejected so often as it is statutorily excluded, meaning it’s a non-covered routine procedure according to medical insurance and Medicare.
The problem, however, is structural. It is possible for a patient to undergo a covered medical eye examination and a refraction simultaneously. Medicare will cover the medical examination, but the refraction cannot be covered regardless of whether it is needed or not since the statute prohibits any coverage for refraction by structure only.
No diagnosis will change this, nor will any modifier, as the only solution is either to charge the refraction separately as a patient-pay service or add the GY modifier as an indication of non-coverage by statute.
Those practices that do not bill these services separately at the claims level make a bundling mistake that puts the whole encounter at risk of denial. Hence, the practices that file 92015 to Medicare hoping to get paid have made a structural error.
What Does the Future of Ophthalmology Billing Look Like for Refraction Services?
The future of ophthalmology billing for refraction services will become increasingly automated with engine-enabled rules, and front-end financial communication with the patient. The future will be increasingly about pre-submission claim scrubbing to ensure that 92015 passes all payer-specific coverage criteria before a single claim goes out.
The practices that bill for their refraction at the time of service with good patient communication and an Advance Beneficiary Notice when required, generate additional revenues that will elude a paper-based, post-denial refraction billing approach.
The Advance Beneficiary Notice is more than just a compliance piece of paper. It is a revenue protection mechanism that will keep the refraction reimbursement cycle free of payer interference with the medical portion of the encounter.
How To Prevent Refraction Billing Denials Before They Happen
Prevention is always cheaper than the cures; so here is how you can have a structured refraction billing process to prevent denials:
Step 1: Make sure that 92015 is sent to the right payer prior to sending the claim
Refraction codes fall under the exam benefit of the vision plans; so, they do not fall under medical plans or Medicare. It is important that each claim confirms which plan covers the refraction service.
Step 2: Add modifier GY to Medicare refraction claims
Stamp claim 92015 with modifier GY in all Medicare claims to indicate statutory non-coverage and shield the practice from liability as well as direct the bill to the patient.
Step 3: Add modifier -25 on billing of E/M code on the same day
In case both medical eye examination and refraction happen in the same visit, modifier -25 for E/M code is essential. The absence of modifiers will result in denials due to bundling.
Step 4: Collect refraction fees at the point of service
For Medicare patients, let the patient know about the cost of the non-covered benefit before delivering the service. Document the discussion. Collect the refraction fee. It eliminates post-visit billing uncertainty, resulting in cash flow problems and patient conflicts.
Step 5: Audit refraction claims monthly
Select a sample of 92015 claims each month and ensure proper routing, modifier use, and payment. Denials for refractions follow a pattern, and figuring out which one in a monthly audit will cost you less than figuring out which one in a quarterly audit.
How Do Billing Services in Texas Handle High-Volume Refraction Billing?
Billing services Texas, specializing in high volume refraction billing are the ones that have incorporated payer-specific rule sets into their claim scrubbing process. This is due to the fact that Texas payer mix is made up of commercial managed care and Medicare Advantage plans that utilize different coverage logic with regard to refraction.
Those Texas-based practices that are able to consistently maintain a low rate of denial when it comes to refraction are not using any other codes. It’s just how they route the claims. Eminence RCM, with its unmatched billing services Texas is aware of the commercial plans that bundle 92015 into the exam code, those who need to be separately submitted and the Medicare Advantage plans that use different coverage logic compared to original Medicare.
For getting your refractive billing sorted, reach out to Eminence Healthcare Services now!
Frequently Asked Questions
CPT 92015 falls within Medicare's statute of exclusion under Section 1862(a)(7) of the Social Security Act, which states that Medicare will not pay for routine eye care services, including refraction. The statute of exclusion is not based on a medical necessity assessment. It doesn't matter what the diagnosis or the medical reason for the refraction is. A practice can invoice patients directly for the refraction, if they were notified about the non-covered charge prior to the service.
Yes, you can bill a patient for Refraction if Medicare denies it. As this is a denial due to statutory exclusion, the practice has the right to bill the refraction charge to the patient. An Advance Beneficiary Notice (ABN) is not necessary when a claim is denied by statutory exclusion, but most practices use it anyway to be sure that the patient was notified of his/her personal responsibility prior to the service.
If both an eye exam and a refraction are done during the same visit, modifier -25 must be used on the E/M code to prove that the E/M was separately identifiable from the refraction. In the absence of modifier -25, payers will often bundle the two services and deny or under code the exam. Modifier GY should be used on 92015 for Medicare claims, indicating statutory non-coverage.
If 92015 is bundled on an eye exam claim erroneously, either by EHR software error or by manual error, then the whole claim becomes at risk of rejection, not just the refraction line item. The payer who uncovers the mistake will often deny the whole claim, rather than adjudicate only the eye exam component. Appeals for recoupment of this lost revenue will often prove costly and unsuccessful.
Yes. While many vision plans include refraction as part of their covered eye exam benefit, some plans separate it as a carved-out service and have their own cost-sharing requirements. In medical insurance, refraction is considered a non-covered service. The process for submitting refraction charges will have to determine the right coverage that applies to the patient since routing 92015 to the wrong payer type is among the most common reasons for systemic denials of refraction services.
Optometry practices should audit their refraction billing monthly. Refraction billing issues are systematic since they are always found in the same claims since they arise from process gaps and not single incidences of billing mistakes. By conducting a monthly review of 92015 claims to verify how it was routed and what modifiers were used on them as well as the outcomes, any patterns that could turn into financial losses can be identified.
Still have questions?
Contact Us.webp)
