# Optical Forums > General Optics and Eyecare Discussion Forum >  Billing for refraction?

## medieval1

Split? Or not to split? That is the question!!!There seems to be some sort of confusion as to whether a refraction is included in certain ophthalmic codes, or if it has to split out. Apparently, Medicare requires it to be split out, but BCBS feels this is unbundling. How are the rest of you dealing with keeping this staight, and knowing when to split, or not?

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## chip anderson

If one reads the Eye Care I ruling it states: "The written Rx must be given to the patient in writing whether requested or not at time of examination."  This would imply that one cannot do an examination without refraction.

Now medicare's stance is different, don't know how one resolves this.

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## NC-OD

There are ten elements of an eye exam:

1. Confrontation fields
2 Eyelids and Adnexa
3 Ocular mobility
4 Pupils/Iris
5 Cornea
6 Anterior chamber
7 Lens
8 Intraocular pressure
9 Retina
10 Optic Disc

A comprehensive exam consists of 8 or more of the above elements
An intermediate exam consists of 3 to 7 elements.

That's it. Refraction is not included at all. It is 100% seperate and optional. In fact you can do comprehensive exams all day long and never touch a phoropter.

Refraction should be billed seperately. BCBS, UNHC, Tricare and others pay upwards of $50 for the refraction over the exam fee (and UNHC reimburses so poorly you should take what they give you). Medicare has, in the past, required you to bill the refaction to the patient but has since relaxed that requirement. It is optional but, of course, you must bill everyone equally.

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## chip anderson

NC-OD


Can a patient call in and schedule for a "refraction" and not undergo or pay for all of the other elements of "a complete eye exam?'

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## NC-OD

> NC-OD
> 
> 
> Can a patient call in and schedule for a "refraction" and not undergo or pay for all of the other elements of "a complete eye exam?'


Not in my office. I won't accept the liability. I'm too scared of the ambulance chasers. :o

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## UFRich

We bill the refraction seperately in our office for the refraction.  NC-OD, I am finding BCBS of FL denying payment for the refraction and considering it pt. resp.  Do you thinking I may be billing incorrectly?  Thanks for any info.

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## medieval1

That is essentially the same problem we are running into in my office as well. For medicare.we are to split the refraction out, docter;s direct as well. however, BCBS will not pay the speperate refraction, we have toroll the fee fro the refraction into the exam fee. What NC-OD says makes perfect sense, but it seems to be impossible to apply. Is there a different way to bill if the exam is billed under medical? If routine, does the refraction then become part of the "package"???

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## drk

http://www.findarticles.com/p/articl...12/ai_n9472935

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## ilanh

Refraction is never part of the eye exam.  It is not covered by most insurances, never by Medicare and is always considered seperate.  I dread the day when it will be considered bundled into a complete eye exam.  On that day we will all lose a lot of our revenue.  We charge $29 additional for a refraction and every patient is informed about that upfront.

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## medieval1

That is what i thought, however, we have been adding the cost of the refraction to the eye exam, and billing the total combined cost of the two to BCBS and United Health. This was based on the information given to us by our last insurance person, who says she called the seperate insur. companies and asked them how we were to do it. So we are incorrect in doing so? ~sigh~

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## NC-OD

> We bill the refraction seperately in our office for the refraction. NC-OD, I am finding BCBS of FL denying payment for the refraction and considering it pt. resp. Do you thinking I may be billing incorrectly? Thanks for any info.


My insurance person, who I sleep with (and I'm married to her) tells me that most BCBS plans here in NC will pay us for refractions when billed seperately (92004 and 92015). Sorry, I don't have the specifics on which BCBS plans will pay and which won't.  My theory is that it really depends on what kind of 8th grade graduate handles the claims as they come in.

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## chip anderson

Just a thought: But when a patient calls you and wants an eye exam, unless there is pain, puss or loss of vision, *what the patient wants is a refraction*, the other benefits, i.e. screening for disease are just co-incidental from the patient's prespective.

When a patient comes in for glasses, he usually wants to see better, she wants more style and all the other add-on's, latest no-line, coatings, etc are also just co-incidental.

Chip
But, then I am not in Beverly Hills.

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## medieval1

> Just a thought: But when a patient calls you and wants an eye exam, unless there is pain, puss or loss of vision, *what the patient wants is a refraction*, the other benefits, i.e. screening for disease are just co-incidental from the patient's prespective.
> 
> When a patient comes in for glasses, he usually wants to see better, she wants more style and all the other add-on's, latest no-line, coatings, etc are also just co-incidental.
> 
> Chip
> But, then I am not in Beverly Hills.


 Ah so..very true, but the desire for a refraction often indicates decreased acuity, usually from causes other than refractive error. Better to provide that comp. ophth. exam, explain any vision loss to pt, so they dont return a week later ( with a blood sugar of 300!!!*L*) complaining about "our" Rx and "your" specs!!!
Also, don't underestimate the pt's need for all the bells and whistles where their specs are concerned. Of course they dont want those, not yet anyway!!! I personally have so many "optical accoutrements" on my specs I am seriously rethinking my need for eyeballs!!LOL.

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## UFRich

NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.

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## chip anderson

UFRrich:  You people have just established that the _refraction_ is not part of the _important medical exam. _ So why shouldn't it be cheapened.  It hasn't been too long since a "complete eye exam" by an MD including refraction was $15~$35 if no items requireing medical attention were found.

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## NC-OD

> NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.


I think I mentioned before. United Health Care is absolutely the work plan I deal with (I don't take any vision plans). They deny refractions 100% of the time but will pay when we spend 45 minutes on the phone with them as they admit they "made a mistake". 

Then we repeat the process the next time:hammer: They should be in prison for fraud.

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## UFRich

> It hasn't been too long since a "complete eye exam" by an MD including refraction was $15~$35 if no items requireing medical attention were found.


I am sure NC-OD can back this up. Our OD may perform 1 out of 100 exams that have no medical diagnosis. If the ODis performing a "complete eye exam" they will almost surely find a medical diagnosis, which could be as simlpe as dry eye. This would also require the Dr. spend more than 15 min in the exam room with the pt. Unfortunately, the are OD's kicking out Rx's in 15 min or less and only performing a refraction in most cases and telling the pt they have had a "complete eye exam", when the could get the same result from an auto refractor.




> You people have just established that the _refraction_ is not part of the _important medical exam._


Its not that the refraction is not part of the "important medical exam", insurance companies (todays mafia) do not consider it part of the "comprehensive eye exam". 

Ultimately it comes down to why you are in business. If you are there to provide a quality medical service, then you must spend alot of time explaining to pts. why your fees are more than the guy down the street who is just doing refraction.

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## chip anderson

URich:

Precisely my point, a medical diagnosis (before insurance companies were involve) including "dry eye" was seldom found in an examination in years past. Now that O.D.'s can make "medical diagnoses" and M.D.'s are out for every buck that exists. Every patient has a "condition". Every medicaid, every medicare patient needs glasses. Even though the incidence of +0.50 -0.50 x whatever is probably 1000% higher than in years past. We have all become corrupted and I don't think it will ever end.

Chip

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## UFRich

You are probably right Chip.  I am sure there are many OD's only concerned with max billing.  I believe in my OD and have gone around with him many times for not prescribing glasses when the optical needed sales.  Ultimately I agree with him to not give somone something they dont need.  The only way back is to educate the  public of the need for quality medical eyecare and set fees accordingly.  Our cash pay eye exam is $89, and we have very few complaints after the OD spends most of an hour with them.  They are educated as to the completness of the exam they just had.  We would rather do cash exams all day over ins. billing, even though we can get more money from the ins. companies.

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## jediron1

UFRich
NC-OD, I am sure you are correct about the 8th grade grad comment. We file using the 92015 and most plans in FL deny payment. We also inform the pts. upfront about the refraction fee ($30 IN OUR OFFICE) and many still complain. Unfortunately there are too many establishments in our field, that will remain unnamed, that have lowered eyecare to the level of getting our nails done, rather than an important medical examination of the eyes.[/QUOTE]

Would the name less one's be Sears, Costco, Sam's ect ect.?Just had to ask! :Eek:

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## fvc2020

Good Morning everyone


I do all the billing in my office and never to I not know who is paying refractions and who are not.  With the exception of Medicare and Eyemed(who never pay the refraction), I get paid on it everytime.  My staff calls and veifies routine vision coverage, medical office visits, if there is other insurance we need to know about.  We do alot of vsp, bcbs of any state, health partners, medica, UHC(who will pay the refractions after I personally provide proof it's listed in there benefit package).  I am even paid refractions on all of my medical assistance patients.  If you are not getting paid you need to see why.  We do bill seperatly using 92004 or 92014, with of course 92015 for refractions.  Usually never a problem.  As for doctors finding medically issues, I have yet to have my doctor find one just so we can get paid more.  We bill the fullest amount that we can, so it makes no difference.  Does she find medical issues?  Of course, but routine is routine.  

I have learned that taking care of the patient to the fullest is my doctor thing.  We discuss with patient all our findings and let me say with pride our exams run 30-45 per person.  She will not give glasses just to make money,even when I ask her to.  We don't bill for the heck of it.

Just my thoughts on the subject:) 

Christina

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## ilanh

The majority of PPO's will not pay for refractions unless there is a vision plan bundled into their insurance. My office deals almost exclusively with PPO's and Medicare and we have found that most PPO's don't cover refractions.  It's possible that Christina is having "no problem" with collecting refraction fees because their office selects for insurances with vision plans.  Or perhaps in an optometric setting the patients have self selected themselves to see an optometrist only when they're sure they have a vision plan.  However, I can assure you that with PPO's you never know who is going to cover it and who will not (many many don't).

Ilan

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## Lucinda74

I have an interesting one where the MD billed a medical e/m 99213 ($75) and a refraction ($25). The carrier keyed the claim as $0 for the 99213 and then applied the cost of the office visit to the refraction which they of course denied saying that routine vision is not a covered benefit. They're saying that you can't bill an OV with a refraction b/c they are one in the same... Am I missing something? The dx was Amblyopia.

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## chip anderson

Should be one and the same.  Just now that some carriers now have a new box to check some prescribers are trying to make more money out of it.

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## orangezero

Actually, I think its more in error to assume or want all eye exams to be the same.

More should be done to educate the patient about what is being done and how that may differ from a "routine" exam.

I know, most people show up to get glasses, right?  

Yesterday I had a dude ask me if these new glasses were going to correct his color vision.  What are they teaching people in these mandated vision self-diagnosis classes?

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## ADO

I believe you have to go back and look at what the insurance plans cover. The routine vision plans, like VSP, are there to cover routine visits plus a refraction for glasses. A routine exam includes the 10 elements that NC-OD described above, but does not cover the treatment of eye health issues. The medical plans cover the same 10 elements plus the treatment of any eye health issues. They do not, with any regularity, cover refractions. Knowing this you have to either have a separate charge for your refraction or you have to be willing to give away services. If you bill a medical plan and they say they don't cover the refraction then it is the patients responsibility.
It is very important to know why your patient is coming in. Most patients, and some OD's, automatically assume that when the patients PCP sends them in because they have diabetes they can use their routine vision plan to cover it. That is not the case. This patient is being sent to you for your expertise on a medical issue. This patient should have there medical insurance billed and not their routine. If they have a routine plan they can choose to make another appointment to have their refraction covered or they can save themselves a trip back in and pay the refraction fee. If we continue to bill routine plans for medical issues it won't be long before we are forced to treat eye health issues under routine plans. If that happens then we are all in trouble because their won't be enough OD's around to keep us all employed.
At the last practice I managed we always collected the refraction fee from the patient when we were billing medical. If we were able to get paid on the refraction we refunded the pt.

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## orangezero

Good points ADO.

The problem with all of this is the patients don't really understand their coverage, and its implied that vision plans do cover these types of things by the vision plans themselves.

There is even some trickery about to coerce eye docs into accepting vision plan type reimbursement for these medical issues.  Patients generally don't care, its all the same to them.

Vision and Medical Insurances laugh all the way to the bank (with the patient's money) with the providers who dramatically undervalue their services or even give things away for free.  Lord knows they are not really cutting any of their profits to help us out.  It is almost entirely taken out of the providers pocket, but there is a long long history of this.

I think the only good answer is to drop all vision plans and start having patients take advantage of flex spending and health savings accounts.  No big provider catalog to look through means the vision plans loose all their "power."

Like this will ever happen, though.  Too many people thing they can play the system without getting taken advantage of.

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## ADO

I think the only good answer is to drop all vision plans and start having patients take advantage of flex spending and health savings accounts. No big provider catalog to look through means the vision plans loose all their "power."


I know an OD who dropped all routine vision plans. He only accepts the medical plans. 

Bad news: His revenue dropped to a third of what it was before.

Good news: He was able to work 2 fewer days a week.

Great news: He was more profitable then ever before.

Very gutsy, but overall a great move for him.

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## HarryChiling

> Yesterday I had a dude ask me if these new glasses were going to correct his color vision. What are they teaching people in these mandated vision self-diagnosis classes?


Well most of the patients don't have acess to the OD's or OMD's like they do to opicians, secretaries, and techs.  Most offices won't pay for educated staff instead they use the old tried and true (yeah right) "I'll teach them myself", but since the OD's or OMD's time is too valuable to wast eon staff the staff just picks up what they can on their own, after a while you will catch your staff telling patients the most asinine things.  That's how some of this bull gets out there like "will these correct my color vision".  Some where in the US an optician probably right now is telling someone "yes they will".

Chip I agree, I do think that more and more doctors are looking for the diagnosis.  When I started the goal of an average exam was get them in get them out (more patients = more money) now it seems the goal is spend enough time with them to find a diagnosis (find something = more testing = more money).  Can't say I blame them and on top of it the patients walk away happy, because they truly felt  hte doctor spent alot of time wit them and listened.  I have seen patients being billed medically for allergies and when I ask if the allegies are bothering them they say "NO" and usually question why I asked (ophthalmology practice).

I say unbundle the refraction, because I'm sure this won't come as a shock to anyone *a refraction is not medical* IMO, in the isurance companies opinion, in the patients opinion, and probably a few others as well.

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## shellrob

> I have an interesting one where the MD billed a medical e/m 99213 ($75) and a refraction ($25). The carrier keyed the claim as $0 for the 99213 and then applied the cost of the office visit to the refraction which they of course denied saying that routine vision is not a covered benefit. They're saying that you can't bill an OV with a refraction b/c they are one in the same... Am I missing something? The dx was Amblyopia.


The person doing the billing made a mistake-simple as that. You need to call and they will straighten it out. It's happened to me many times. 

As far as billing refractions, the reason they get denied is because that person doesn't have coverage for vision services. Period. Just like Illanh said.They have a medical insurance that doesn't pay for it. We also bill the refraction seperate as well because they require us to. The only times we ever do JUST a refraction would be if the patient just came from our MD next door and needed an rx for glasses, only exception. I couldn't comprehend any doctor doing just a refraction on a patient. Sounds like a lawsuit waiting to happen.

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## orangezero

I did forget to mention that.  Medical insurance companies make more money by denying claims.  Simple.

If you bill for an exam and a foreign body removal, they may only reimburse the lower paying fee and hope you don't see they forgot to pay the other.  How many times do offices not notice?

Also, there are some plans where you have to bill a refraction to a carrier, get a denial, and then bill to patient.  You can't just bill to the patient to begin with.  Lots of stupid stuff like that.  And each plan is allowed to have different policies.

There has to be a better way.

I bet if patients paid out of pocket for everything and then got reimbursed by the insurance companies after sending in the info, there would be lawsuits and federal investigations within a year because of all the deceit that goes on with their questionable billing practices.  Consumer advocate groups wouldn't put up with it.  

But the way it is its left up the office staff at the doctor's office, and then they have to pass those extra costs along to their patient's in the form of higher fees.

It just amazes me all the people involved in health care who do nothing but shuffle papers, in both the doctors offices and the insurance companies.

The only hope is computerization, but I doubt it will solve much of anything.

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## chip anderson

I'll bet if asked 90% of those patients with no history of pathology and no symptoms would say if asked: "I just want to get my glasses prescription checked."  They would be gratefull and accept treatment if pathology found, but the reason they came was "I just wantto get my glasses prescription checked."  
In the past this has always been why the patient was there and what a routine exam was for.  Now that O.D.'s can treat and used drops I don't know if they are after higher fees or terrified that the new powers will be resended if one is found lacking on the "thoughness" of his exam.
Were O.D.'s sued daily in the past when they couldn't dillate, use drops, or treat medical conditions?
Were they sued daily when they "jumped the gun" in treating these conditions prior to legislatures granting such powers?
Chip

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## ADO

To back up what Orangezero is saying:

We actually had a big insurance carrier drop us as a provider because we consistently second guessed their payments. 
Whatever level of exam we billed they would automatically drop it a level and pay that amount. We would then take the step of re-filing the claim and get it corrected. After about 6 months of this they dropped us saying that we caused them too much work and that other doctors in town accepted their payment methods without question so they were going to refer their members to those doctors.

I wonder how many of the doctors even know they were getting paid less then they contracted for?

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## drk

Some docs bend the rules to "upcode" a routine visit to a medical visit.  

Sometimes because it will save the patient short-term expenditure.

Sometimes because it will enhance the doc's reimbusement.


Bottom line is that patients present for:
1.) Medical care
2.) Vision care
3.) Both

and it's up to the doc to determine what the reason for visit is, and who's on the hook to pay.

Routine/preventative care is not universally covered by health insurers, probably to the detriment of public health.  Preventative care is an individual's responsibility, as is.

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## orangezero

That is a valid point chip.

However... public perception is that everything can be "fixed" with eyeglasses.  Commonly it can and these are the times you are thinking of, but there are very common issues that can't be.  And more importantly, even if a patient has every systemic and eye disease in the book, they still present for "just want glasses."  And then either during the history or during the exam it will come up that they have dry eyes, uncontrolled hypertension, untreated glaucoma, and a diabetic retinopathy.  But just fix it with glasses, please.

And another point worth mentioning:  things have changed since the 1950s, 70s or even the 90s.  For example, back "in the day" patients went blind from glaucoma.  Now we have some tests that can detect and delay or prevent symptomatic visual complications.  

Medical providers in this day and age don't have the option of practicing "1950s style standard of care."

When is the last time you had someone come in your shop and say, "gee, I don't see that well, perhaps I have glaucoma?"

I don't think optometrists perform additional testing out of fear of loosing their legal rights.  Most malpractice cases involving optometrists have traditionally involved failure to perform procedures that an optometrist (or ophthalmologist) would do in a similar situation and that causes the patient harm from the lack of care.  Perhaps more of a CYA than anything, but I think its just silly to think someone who give up years of their life just to screw over patients.  So many other ways to make money in life besides health care (unless you are involved with providing coverage I guess).

You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide.  Chronic issues are no treat to live with.  Be careful what you downplay at superfluous.

To summarize:
Patients don't (and aren't expected to) understand what is involved with their visual symptoms.  It is the optometrist's or ophthalmologist's job to figure out the reason actually is even if it can't necessarily be understood by the patient, although I would hope it could be explained to patients in an easy to understand way.  It can be refractive related or medical related.  Society has placed a larger value on dealing with those medical issues.  I'm sure you can understand why anyone would prefer to be paid for what they do, instead of what is cheapest for insurance companies.


Another interesting point.  Virtually no patients even know that a medical eye issue is covered under their medical plan they already have, they think its covered under their vision plan.  Why is this?

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## orangezero

ADO,

I've personally seen several area ODs undercharging on a consistant basis to "avoid an audit."  So, they are basically getting underpaid for all of their services.  There is quite a range, but my general feeling is that medical eye care has been done for essentially free for so long that now that we actually have the legal rights to submit to a patient's medical insurance it just seems odd.  I can certainly understand the confusion, but the condemnation of getting paid for what practioners do is silly, IMO.

Generally, insurance company hot-line lines are staffed by people following orders, often incorrect orders.  Its just stupid they can't follow their own rules.

And Drk, probably a more succinct summary than me!

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## ADO

Orangezero and Drk,
If I ever get back in the private practice side I am looking you two up. Very refreshing to see doctors take responsibility for having the money conversation with their patients. Too many times I have seen it left to the young receptionist who is clueless on how to handle it. It can be an uncomfortable conversation, but if you handle it correctly it is usually not a problem at all. 

Great job to both of you!

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## chip anderson

Anyone remember when doctors got patients by referral from satisfied patients?  Insurance just paid 80% of the bill.

Does this mean that elderly sucide could be prevented by the simple cheap application of castor oil drops?

Gee, we can have fun with this post.

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## 1968

> You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide.


I'm skeptical. How many number one reasons are there?




> Patients don't (and aren't expected to) understand what is involved with their visual symptoms.  It is the optometrist's or ophthalmologist's job to figure out the reason actually is even if it can't necessarily be understood by the patient, although I would hope it could be explained to patients in an easy to understand way.  It can be refractive related or medical related.  Society has placed a larger value on dealing with those medical issues.  I'm sure you can understand why anyone would prefer to be paid for what they do, instead of what is cheapest for insurance companies.


I agree with this. In my (biased) opinion, 92015 should be a covered service in that the underlying reason for "blurry vision" frequently cannot be determined without it.

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## orangezero

there are 17 number one reasons, duh!@@@

oops.  my mistake.

The point of the lecturer who was making the point was not that we are saving seniors from commiting suicide, but rather that it is a bigger issue than most give it credit for.  Dry eye has long been poorly treated and a lifetime of patients have been silently suffering with it because they didn't know it was something that could be dealt with.  I know for a fact I've never saved a senior patient from suicide, but it has made me ask about dryness more than before.

And the causes and solutions to dry eye disease (anterior surface disease, what have you) are only now starting to be adequately addressed.  The answer isn't simply to have the patients insert castor oil drops 15x per day, because there are better ways to deal with the cause of it, not just the symptoms.  Its not just the dryness, but also the redness and irritation, and sometimes the social stigma that goes along with it.

But you do have to go out on a limb and say our tear production system, our eyelids, and our cornea are a part of our body and if they aren't working correctly it actually is a medical condition/disease.  Previously, practitioners did just give drops and "next please."  Perhaps that wasn't worth a whole lot back then, but once again times are different.

Which do you want Chip?  Do you want us to spend more time with patients and solve their problems, or do you want to do whats cheapest and what you've always been accustomed to?  Its not making money out of thin air, these patients have problems and we now have solutions.

How dare we expect them to pay for our expertise, is that what you are contending?

I just knew that dry eye thing would get comments :idea:

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## chip anderson

Actually Castor Oil four times a day will *cure* almost every case of keratitus dissicica eventually.

Where did I get this?  From Dr. Louis Girrard, M.D.

Where did he get it?  Back in the late 50's and early 60's anesthesiologists were using anesthesia that kept the patient's eyes open during non-opthalmic surgery.  They didn't like the patient's corneas cracking so they
carried Castor Oil and dropped it in, the patient could be kept out for hours without corneal damage.  Dr. Girrard started trying it on the worst cases of keratitus dissicca which were sent to him while he was chief of Baylor Medical's Ophthalmology Department.  It worked.

Why doesn't anyone prescribe this?  It's not FDA approved as it's not patentable.  Today's doctors are far more afraid of lawyers than intersted in the patient.

Chip

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## orangezero

Endura?
Restasis has castor oil?

I don't doubt you or the doctor you mention.  However, a perfectly "normal" patient who is having their eyes held open and requires some type of tear shield is a bit different than the numerous other ways patients are affected with what the layman would term "dry eye."

What castor oil are you recommending to your patients?

Honestly Chip, your distain for the average doctor is disheartening.  We have feelings too (even the nonMDs you don't consider doctors).  The real heartless, out for profit, dudes are in other businesses swindling you out of even greater amounts of money on a daily basis.  So many betters ways to bring home the bacon that medical care.

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## chip anderson

Orange:  I don't make any money if the doctor recommends castor oil, the doctor doesn't, the drug store doesn't appreciably, and for all practical purposes the patient has no expense.  While the little drug detail girl in the miniskirt does make a tempting presentation for restasis, it fails and castor oil doesn't.  Now I don't know how money and greed got into this, as the preventative mentioned was fear of lawyers.  
But why Rx things that only work from the chair to the parking lot when the cure has been around a long time, cost next to nothing, has no adverse effects, and actually work?  Of course I admit that doctors must get a lot of pressure from patient's seeing direct to the public drug commercials and asking: "Doctor can I take this?"
Doctors must hate this.

You may not recognise this, but I am trying to help you with this, if you are patient motivated.

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## shellrob

Orange is right, the majority of patients think that any visual problem they are having will be fixed with glasses. We all know this isn't true. That's why one cannot do JUST a refraction. That's a major disservice to your patients. So, if they come in JUST to get an rx for glasses and tell you they don't want the "other" parts of the exam, and you find a cataract-you won't tell them because that's not what they're there for? Give me a break. Some people on this board think that doctors(specfically od's) are just out to make money. Give me a break. I'm not saying therer aren't some out there like that, but their not ALL like that. I think that O'd are highly underpaid for treating some of the same things Mds treat.That's a fact in itself and some od's just want to get paid the same for the same treatment. Rightfully so.

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## orangezero

Correct, not a fan of direct-to-consumer advertising.  Don't know many who are.

I'd prefer not to get too wrapped in the whole money/greed issue myself, sorry to go there.

I'm curious why you think restasis doesn't work?

I haven't checked in store (you've got me curious), do you tell patient's to get the stuff on the shelf you use for vomiting?

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## HarryChiling

> Orange is right, the majority of patients think that any visual problem they are having will be fixed with glasses. We all know this isn't true. That's why one cannot do JUST a refraction. That's a major disservice to your patients. So, if they come in JUST to get an rx for glasses and tell you they don't want the "other" parts of the exam, and you find a cataract-you won't tell them because that's not what they're there for? Give me a break.


Just out of curiosity what are these conditions that only a refraction can pick up?  GIVE ME A BREAK.  That's the excuse used to make sure opticians never refract not an actual truth.

The arguement has always been if the refraction is split from the exam then no one will want to get an exam they'll all want refractions and yes people do think that glasses will solve everything, but OD's have historically been the ones to prescribe glasses so where along the line did OD's drop the ball.  

The medical arena has just now opened up to OD's so now everyone needs to focus on the medical side of things.  Wouldn't it be correct to say that 50 years ago the medical eye exam was just as important as it is today.

----------


## MarcE

> Wouldn't it be correct to say that 50 years ago the medical eye exam was just as important as it is today.


No, it would incorrect to say that.  It's more important now because

1. The standard of care is greatly increased and more precisely defined, therefore,
2. The chances of being sued have increased many-fold, and most importantly,
3.  The treatments available now can prevent diseases and greatly enhance quality of life like couldn't be done 50 years ago.

50 years ago, the public didn't care for or pay for preventitive exams or care.  Now things have changed.  The general public wants and is willing to pay for preventative health exams.

Yes Chip, things have changed.  OMDs don't go to school for 12 years at a cost of $200K and a forgone income of another $500K just so they can bill $39 for an exam including a refraction.  But gasoline isn't $0.29/gallon anymore either.

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## HarryChiling

> No, it would incorrect to say that. It's more important now because
> 
> 1. The standard of care is greatly increased and more precisely defined, therefore,
> 2. The chances of being sued have increased many-fold, and most importantly,
> 3. The treatments available now can prevent diseases and greatly enhance quality of life like couldn't be done 50 years ago.
> 
> 50 years ago, the public didn't care for or pay for preventitive exams or care. Now things have changed. The general public wants and is willing to pay for preventative health exams.
> 
> Yes Chip, things have changed. OMDs don't go to school for 12 years at a cost of $200K and a forgone income of another $500K just so they can bill $39 for an exam including a refraction. But gasoline isn't $0.29/gallon anymore either.


Let me rephrase then how about 10 years ago?  The point I was trying to get across is that now that OD's do have the right to bill medically doesn't mean the world has all of a sudden changed.  Before the medical billing I remember that OD's pushed for more exams through the door now that may have meant missing more pathology, but that was how things were done, now with medical billing the idea is spend more time with the patient and if you find a diagnosis jackpot.  

Now all said and done yes I enjoy this way a whole lot better than the old, more time spent with patients and less diagnosis missed a great thing indeed, but it should have been this way 10 years ago or 20.  The standard has gotten better I agree, but to say that the old standard wasn't adequate would be false.  Now if this way of thinking were to continue if OD's were to be allowed to perform LASIK, then all of a sudden glasses and contacts would be the old way of doing things and no longer recommended.  That would be the outdated standard of care.

The scope of p[ractice of an OD has increased and now this is the growing pains that unfortunately go along with it.  The general public doesn't want or think they need this service, because in the past they have come to the very same doctors and not recieved these services so they don't see the value on them.  I would have to say that sometimes I don't either, for instance OK you found out the patient has dry eyes, you give them something to help, but the difference now is you want to see them back and you bill medically for this second visit.  Before you would give them the drop and be done with it.  In some cases when they come back if it didn't help you try something else and this creates a trough that everyone feeds from.  Then when my insurance premiums go up, because all of a sudden theirs another hog in the trough.

This will enevitably lead to lower reimbursements from insurance companies whihc will then lead to OD's needing to expand their scope again.  It's an endless cycle, but the whole idea of the level of care getting better is pure crap when in the end the optical which is where most end up purchaseing corrective devices is still the area most ignored.  Sure perform a spot on exam testing for everything under the sun with the latest and greatest in equipment all while the person operating this equipment has less at best a high school education and the person dispensing the devices to help correct the most commonly prescribed devices from the office (contacts and glasses) doesn't have a clue what they are doing.

The standard hasn't changed the the way in which they get payed.

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## chip anderson

Orange: 
 I have seen many, many patients who found that restasis didn't work or provided only momentary relief.  Castor oil isn't for vomiting it's to cause things to pass through the bowel.  And yes, the stuff on the drug store shelf is the same stuff.  The stuff in the paint store is toxic.

In the fine print you will find that restasis provides only temporary relief, not a cure and it lowers one's immune capabilty to infection, castor oil does not.

Wouldn't you like your patient's to tell other patients that you were that wonderfull doctor that told them about this. Cured them of the problem and they didn't require and Rx and it cost next to nothing.  Above all it worked.

I'm not sure how it works for you professionals but as a non professional and as a suggestion for which no fee is charged, one is not practicing medicine or optometry.  Just being a helpful friend.

Chip

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## rdcoach5

Chip, how often and what brand or strength castor oil did the Dr use. Was it specially purified or distilled? I would recommend it for a co-worker but I doubt I could convince her to try it.:finger:
              Bob Taylor

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## rbaker

One thing seems clear when you put all of the legal, moral and ethical issues aside, most MDs and ODs decision whether to bill or not bill will be based on their pecuniary interests. We use the system when it adds to the income and ignore the system when it costs us money. I am not being judgmental, just observant.

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## orangezero

> Orange: 
>  I have seen many, many patients who found that restasis didn't work or provided only momentary relief.  Castor oil isn't for vomiting it's to cause things to pass through the bowel.  And yes, the stuff on the drug store shelf is the same stuff.  The stuff in the paint store is toxic.
> 
> In the fine print you will find that restasis provides only temporary relief, not a cure and it lowers one's immune capabilty to infection, castor oil does not.
> 
> Wouldn't you like your patient's to tell other patients that you were that wonderfull doctor that told them about this. Cured them of the problem and they didn't require and Rx and it cost next to nothing.  Above all it worked.
> 
> I'm not sure how it works for you professionals but as a non professional and as a suggestion for which no fee is charged, one is not practicing medicine or optometry.  Just being a helpful friend.
> 
> Chip


Rant mode :ON:


Good point Chip.  I do only need one (1) patient to buy the stuff at the paint store, go blind, claim I gave them the wrong directions, and sue me blind. :( I recommend standard non-prescription remedies all the time, but only things I'm comfortable with, and only to certain patients I can trust.

That is essentially the point.  The world HAS changed.  I just listened to a lecture on malpractice today (how timely), and they provide some pretty clear examples on just how crazy the whole system has gotten.  Unfortunately, we can't practice in our own little bubble and ignore the outside world.  Certainly we can't just do everything based on the potential for malpractice, but it is ever present and to think otherwise is foolish.

And Harry, you are perhaps incorrectly integrating every segment of the eye care industry into one huge mass to fit with your idea of whats going on.  Some places have always been concerned with pushing people through as quickly as possible, and that isn't going to change no matter what insurance ODs can bill.  Others have been billing medicare and other insurances for over 20 years.  There are a lot of people who will crash and burn trying to do both.

It is a confusing history, and greatly depends upon who tells it.  My take is that its a combination of changing standards of care due to increased technology just as much as it is scope of practice changes.  But its mostly interrelated.  ODs getting the right to dilate and prescribe medications opened the door for the potential for malpractice.  And new technologies that allow for earlier treatment of previously blinding conditions in many cases call for more routine screening and detection.  To do otherwise is malpractice and whether you like it or not, we are responsible for their health even though they may ignore it.

Example:  Glaucoma.  We barely learned about pachymetery in school, but now almost everyone recognizes it as standard of care for a glaucoma suspect.  And things are now turning to laser imaging as almost becoming standard.  It absurd to think ODs should be required to perform these tests while not be reimbursed, or to think them greedy if they do.

I shouldn't have to tell you all the cost to our health care system if a person goes blind or has a serious visual impairment, but its HUGE, and probably some economist could rationalize all the preventative care offered by eye care providers as more than offsetting this.

Another example is the new anti-vegf drugs that are starting to come out.  Just a few years ago there wasn't much that could be done (or done effectively) for ARMD or clinically significant diabetic macular edema.  Now, these drugs are literally being tried on almost anything that is related to retinal vascular issues.  Just a few short years ago the treatments were nil or barbaric at best.  So, what before was "we can't do anything for you" has become, "lets take a closer look at that to decide if this new treatment is right for you."  Doesn't imply anywhere in here that I want to inject these drugs, but ODs and ophthalmologists need to be able to detect their presense.

Both these examples are just within the last year or two.

I have several types of patients.  But I often get the comment that their eyesight is important to them and they are glad the just got a thorough exam and sat through a dilation.

I also have the ones who expect me to do all of their health care for pennies on the dollar, or what in another setting would be well over $200.  

I'll stand by this, eye care is perhaps the cheapest and most easily accessible of all the health care fields.  You can get in anytime, and find almost any sucker OD to deal with your hypertensive retinopathy, diabetic retinopathy, thyroid eye disease, cataracts, "mild" glaucoma, dry eye, eye allergies, and still fit them for contacts and write a prescription for less than what most other health professionals charge for a no-show fee.

I don't know why you guys are complaining, there is cheap everywhere.  Tons and tons of ODs charge little more than a happy meal for a full exam (including a sacred refraction).

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## chip anderson

rborach:  
 I don't know, I have just told people to get what's on the drugstore shelf and an eye dropper.  For CL patients one drop per eye in the evening after CL removal.  For others it doesn't matter how often they use it, but four times a day should suffice.  It is hard to convince people that you are serious (especially ophthalmologists) and usually they will only try it after every thing the doctors have Rx's fails, or drops off in effectiveness.
So far the results have Mirrored Dr. Girrard's almost 100% positive results and one or two that felt it stings a little and quit.  No adverse reactions ever.  Even works with patients having dry eye and gooey mucous deposits.

Haveing said this I also think "dry eye" is one of the most over diagnosed malladies in medicine.  Seems to be much more prelevant now that we have puntum plugs and $450.00 surgical fees to install them.  And believe me puntum plugs can cause a whole bunch of problems.

Chip

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## 1968

> Haveing said this I also think "dry eye" is one of the most over diagnosed malladies in medicine.


I believe dry eye syndrome is under diagnosed... and I don't do punctal plugs in my office.

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## MarcE

> I believe dry eye syndrome is under diagnosed... and I don't do punctal plugs in my office.


I also believe it is under diagnosed.  
Chip, if you think it is overdiagnosed, maybe you could start a trend by cutting back on your diagnosing and prescribing treatment of dry eye.

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## rlr.consulting

LADIES AND GENTLEMEN, 
     My name is Andrew Roy and I own RLR Consulting, more information here: http://optometricbilling.rlrbillingsolutions.com. We have been specializing in Optometric Billing services for over 15 years, specifically in Medicare and Medicaid. Over that time I have learned that different insurances are ficcle when it comes to the issue of billing for refractions and dialations. 

     So to my clients I give them this general rule:
*1.) Medicare considers refraction to be part of a routine eye exam and therefore does not require that it be split out. (*ANY ONE THAT TELLS YOU DIFFERENTLY HAS NOT DONE THIER HOMEWORK, IN FACT WHEN BILLED SEPERATELY, THE AUTOMATED SYSTEM WILL TELL YOU IT WAS NOT PAID BECAUSE IT IS CONSIDERED PART OF THE ROUTINE EXAM.) 
*2.) Because you are not required to bill for refraction seperately that leaves you with a dilemma, if you include the refraction as part of your exam you will only be paid about 80% of your total charge, if you bill seperately, you can charge the patient up front in cash thereby collecting 100% and lowering your patient's deductible for the year.* 
*     3.)THEREFORE THE RULE STANDS: BILL THE REFRACTION SEPERATELY AND DO YOUR PATIENTS A FAVOR, THEY WILL THANK YOU IN THE END WHICH WILL ONLY PAY DIVIDENDS TO YOUR PRACTICE IN THE FUTURE.*

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## drk

> LADIES AND GENTLEMEN, 
> My name is Andrew Roy and I own RLR Consulting, more information here: http://optometricbilling.rlrbillingsolutions.com. We have been specializing in Optometric Billing services for over 15 years, specifically in Medicare and Medicaid. Over that time I have learned that different insurances are ficcle when it comes to the issue of billing for refractions and dialations. 
> 
> So to my clients I give them this general rule:
> *1.) Medicare considers refraction to be part of a routine eye exam and therefore does not require that it be split out. (*ANY ONE THAT TELLS YOU DIFFERENTLY HAS NOT DONE THIER HOMEWORK, IN FACT WHEN BILLED SEPERATELY, THE AUTOMATED SYSTEM WILL TELL YOU IT WAS NOT PAID BECAUSE IT IS CONSIDERED PART OF THE ROUTINE EXAM.) 
> *2.) Because you are not required to bill for refraction seperately that leaves you with a dilemma, if you include the refraction as part of your exam you will only be paid about 80% of your total charge, if you bill seperately, you can charge the patient up front in cash thereby collecting 100% and lowering your patient's deductible for the year.* 
> *3.)THEREFORE THE RULE STANDS: BILL THE REFRACTION SEPERATELY AND DO YOUR PATIENTS A FAVOR, THEY WILL THANK YOU IN THE END WHICH WILL ONLY PAY DIVIDENDS TO YOUR PRACTICE IN THE FUTURE.*


Nice post. Can I make a few clarifications?

More precisely, Medicare considers refraction a non-covered service.

"Separating out" refraction fees is inapplicable to medically necessary services and all medical carriers since it's never correct to include refraction with an ophthalmological or E/M code. It's like mixing oil and water. 

As to reducing deductables, I'm not sure if you're saying that refraction has anything to do with meeting deductables or not. If so, I think non-covered services have no bearing on deductables.

As to collecting for refraction, I'm all with you!!

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## rlr.consulting

Generally speaking, no, refraction is not related to deductibles. 

However, if you bill for it seperately and report it on the claim as 92015 and then show cash amount collected as the same amount you normally charge for refraction, it is subtracted from the patient's deductible by medicare when they process the claim.

As for refraction being non-covered, this is not true, it is merely considered part of a routine eye exam, and different carriers do treat this differently. IE, Aetna does pay for refractions as well as medicaid and horizon. In general, medicare is really the only carrier that treats Refractions as part of the routine exam.

Mr DRK, I specialize in helping my clients with issues such as this and these words are true to the T. In fact, if there is anything that I can ever help you with, please do not hesitate to call me, 856.364.7229 or post a request for clarification.

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## orangezero

I've rarely heard it explained this way.  Do you have some documentation to show this, like a medicare .pdf or something similar.  It doesn't really seem to make sense the way you describe it.  For example, if it is supposed to be included, why are we allowed to charge the patient for it (medicare)?

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## LENNY

The key is routine exam!
You bill for medical eye exam!
So refraction could be included in the routine eye exam but not in the medical eye exam!

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## NC-OD

> As for refraction being non-covered, this is not true, it is merely considered part of a routine eye exam, and different carriers do treat this differently. IE, Aetna does pay for refractions as well as medicaid and horizon. *In general, medicare is really the only carrier that treats Refractions as part of the routine exam.*


For someone claiming expert status you seem to have no idea what you are talking about.
Straight from the (Cigna) Medicare website (and based on 13 years of MCR billing experience):

"A refraction is not an element of an intermediate or comprehensive eye exam and is never covered by Medicare. "
http://www.cignagovernmentservices.c...halamogic.html

Medicare doesn't even pay for routine exams.

It doesn't get any clearer than that. Refractions not covered= Patients pay for that part.

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## ksquared

*when Chip posts theres not a dry eye left in the house*

Excerpt from Review of Optometry 2000
The people at Allergan Pharmaceuticals thought they had a good thing going when they approached the FDA last July for approval to market cyclosporine 0.05% (Restasis) as a treatment for dry eye. The two arms of the phase 3 clinical studies had gone well, demonstrating that the T-lymphocyte inhibitor effectively reduces the signs and symptoms of keratoconjunctivitis sicca with minimal adverse events. 

But then something funny happened. The ophthalmic advisory panel for the FDA was less than impressed with Allergans clinical data. The panelists issued a so-called approvable letter listing several points they wanted the company to address before they would recommend approval. We have been reviewing the data and looking to see if in fact we could present the data from those studies in a way that would better present our case, Allergan spokesman Ira Haskell says.

Unfortunately, the two arms of the phase 3 trial did not completely replicate themselves in terms of the signs and symptoms that reached statistical significance, investigator Steven E. Wilson, M.D., wrote in a paper presented last September at a Research to Prevent Blindness seminar. One problem was that cyclosporines vehicle, a castor oil emulsion, may have worked a little too well in the trials.

I dont know that the panel was that impressed that there was that much difference between the drug and the vehicle, says investigator Stephen Pflugfelder, M.D., who testified before the FDA panel on behalf of Allergan. The vehicle itself is better than any artificial tear. You know, if they had compared the drug to artificial tears, they would have won hands down, Im sure. 

Allergan expects to hear back from the FDA by June, Mr. Haskell says. *In the meantime, someone should consider packaging castor oil as a treatment for dry eye.* Apparently, its the next best thing to cyclosporine._R.M._ 

Fast forward to this thread:

orangezero: You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide. Chronic issues are no treat to live with. Be careful what you downplay at superfluous. 

Chip_:_ Does this mean that elderly sucide could be prevented by the simple cheap application of castor oil drops? 

orangezero: Which do you want Chip? Do you want us to spend more time with patients and solve their problems, or do you want to do whats cheapest and what you've always been accustomed to? Its not making money out of thin air, these patients have problems and we now have solutions. How dare we expect them to pay for our expertise, is that what you are contending? I just knew that dry eye thing would get comments.

Chip: Actually Castor Oil four times a day will *cure* almost every case of keratitus dissicica eventually. Where did I get this? From Dr. Louis Girrard, M.D.

Where did he get it? Back in the late 50's and early 60's anesthesiologists were using anesthesia that kept the patient's eyes open during non-opthalmic surgery. They didn't like the patient's corneas cracking so they carried Castor Oil and dropped it in, the patient could be kept out for hours without corneal damage. Dr. Girrard started trying it on the worst cases of keratitus dissicca which were sent to him while he was chief of Baylor Medical's Ophthalmology Department. It worked.

Why doesn't anyone prescribe this? It's not FDA approved as it's not patentable. Today's doctors are far more afraid of lawyers than intersted in the patient.

orangezero: Endura? Restasis has castor oil?

I don't doubt you or the doctor you mention. However, a perfectly "normal" patient who is having their eyes held open and requires some type of tear shield is a bit different than the numerous other ways patients are affected with what the layman would term "dry eye."

What castor oil are you recommending to your patients?

Honestly Chip, your distain for the average doctor is disheartening. We have feelings too (even the nonMDs you don't consider doctors). The real heartless, out for profit, dudes are in other businesses swindling you out of even greater amounts of money on a daily basis. So many betters ways to bring home the bacon that medical care.

Chip: Orange, I don't make any money if the doctor recommends castor oil, the doctor doesn't, the drug store doesn't appreciably, and for all practical purposes the patient has no expense.

While the little drug detail girl in the miniskirt does make a tempting presentation for restasis, it fails and castor oil doesn't. Now I don't know how money and greed got into this, as the preventative mentioned was fear of lawyers. 

But why Rx things that only work from the chair to the parking lot when the cure has been around a long time, cost next to nothing, has no adverse effects, and actually work? Of course I admit that doctors must get a lot of pressure from patient's seeing direct to the public drug commercials and asking: "Doctor can I take this?" Doctors must hate this.

You may not recognise this, but I am trying to help you with this, if you are patient motivated. 

orangezero: I'd prefer not to get too wrapped in the whole money/greed issue myself, sorry to go there. I'm curious why you think restasis doesn't work? I haven't checked in store (you've got me curious), do you tell patient's to get the stuff on the shelf you use for vomiting?

Chip: Orange,I have seen many, many patients who found that restasis didn't work or provided only momentary relief. Castor oil isn't for vomiting it's to cause things to pass through the bowel. And yes, the stuff on the drug store shelf is the same stuff. The stuff in the paint store is toxic.

In the fine print you will find that restasis provides only temporary relief, not a cure and it lowers one's immune capabilty to infection, castor oil does not.

Wouldn't you like your patient's to tell other patients that you were that wonderfull doctor that told them about this. Cured them of the problem and they didn't require and Rx and it cost next to nothing. Above all it worked.

I'm not sure how it works for you professionals but as a non professional and as a suggestion for which no fee is charged, one is not practicing medicine or optometry. Just being a helpful friend. 

*Postscript:*
Sorry Chip, but it looks like the little dish in the mini-skirt won. 

Allergan's RESTASIS Approved by the FDA; The First And Only Therapeutic Treatment To Increase Tear Production In Patients With Chronic Dry Eye Due To Ocular Inflammation

Final Score
Castor-oil (backed by the positive results) - 0
Restasis (backed by the drug companies) - 1

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## drk

I think what he's trying to say, in a slightly awkward ergo unfamiliar way:

If a MCR claim has a 92105 submitted in conjunction with an ophthal. code but zero charge listed, MCR will automatically deduct 20% from the ophthal. code?

I think this may have been true in the past?

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## HarryChiling

> And Harry, you are perhaps incorrectly integrating every segment of the eye care industry into one huge mass to fit with your idea of whats going on. Some places have always been concerned with pushing people through as quickly as possible, and that isn't going to change no matter what insurance ODs can bill. Others have been billing medicare and other insurances for over 20 years. There are a lot of people who will crash and burn trying to do both.
> 
> It is a confusing history, and greatly depends upon who tells it. My take is that its a combination of changing standards of care due to increased technology just as much as it is scope of practice changes. But its mostly interrelated. ODs getting the right to dilate and prescribe medications opened the door for the potential for malpractice. And new technologies that allow for earlier treatment of previously blinding conditions in many cases call for more routine screening and detection. To do otherwise is malpractice and whether you like it or not, we are responsible for their health even though they may ignore it.


The harsh and real truth is that YES people ignore the health of their eyes everyday, there are far more people at McDonalds ignoring the health of their heart, or those at the liquor store right now ignoreing the health of their liver.

You have an obligation to check the health of a patients eye's, it is now through legislation a privledge and a burden.  I do have an issue with a refraction being considered seperate from a comprehensive exam.  Why?  Refraction being inseperable from a medical exam has been the OD's battle cry for years as a reason why opticians cannot perform refractions yet if a patient presents with a cheif complaint of "Blurry Vision", you start with a comprehensive medical examination, then when they check out you offer them another examination, a refraction to determine if it's a refractive error.

If the care is gonna be "ala carte" then why shouldn't the patient have a choice?

Comprehensive and RefractionComprehensive No Refraction*NEVER just a Refraction*The sole reason your profession doesn't feel comfortable offering just a refraction is for fear of litigation, so now the patient has to pay for additional testing beyond what could be necessary every visit to your office because he may want to update the Rx on his glasses or contacts.  This is a disservice, IMO and a niche I think opticians can and should fill.  If the procedures can be offered "ala carte" then the patient should have a choice who provides which components and shoud not be obligated to get all services at one office.

Personally I know many patients that will see an OMD for their health and then go to an OD for the refraction, but the OD has to redo everything all over again. :hammer:

On another health note according to the NEI at NIH between the ages of 40-49 only 5.3% of the population has Cataracts, AMD, and/or Glaucoma.  If you add Diabetic Retinopathy to the mix your percentage goes up to 6.7% of the population. 

Now look at the data for estimated Myopia and Hyperopia it totals to 39.5% of 40-49 year olds.

6.7% medical / 39.5% refractive - Given those numbers which test would you be more likely to have done first?  Also keep in mind the patient has the right to refuse a dilation, I often do.  So then what does a comprehensive exam include?

http://www.nei.nih.gov/eyedata/pbd_tables.asp

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## KStraker

> My insurance person, who I sleep with (and I'm married to her) tells me that most BCBS plans here in NC will pay us for refractions when billed seperately (92004 and 92015). Sorry, I don't have the specifics on which BCBS plans will pay and which won't. My theory is that it really depends on what kind of 8th grade graduate handles the claims as they come in.


Same in SC. Most insurances will screw you if you don't divide it up.

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## MarcE

> if it is supposed to be included, why are we allowed to charge the patient for it (medicare)?


Actually REQUIRED to charge the patient for it.  If you don't charge for it, you could be in trouble during an audit.

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## NC-OD

> Actually REQUIRED to charge the patient for it. If you don't charge for it, you could be in trouble during an audit.


No. No. No. No. No.

Completely wrong.  Many years ago, Medicare would deduct the refraction from the exam fee.  At least 7 years ago, they determined it was optional.  You may report it or not.

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## bwoz

> Some docs bend the rules to "upcode" a routine visit to a medical visit. 
> 
> Sometimes because it will save the patient short-term expenditure.
> 
> Sometimes because it will enhance the doc's reimbusement.
> 
> 
> Bottom line is that patients present for:
> 1.) Medical care
> ...


 
I can't tell you how refreshing it is to hear this from an OD. I self contract billing and I feel like I am always arguing this point. The refraction is a separate procedure. Whether or not a carrier we're contracted with pays it global or deems it patient resp is up to each contract. Sometimes they complicate matters for us more and require certain dx as primary, etc. etc. But if you agree to sign up with them, then that's part of the deal unfortunately. I also feel that a practice can lose money if they aren't billing for all procedures done. In general I always advise that: if you did it, then document it and bill it. If it's not documented, it didn't happen. (at least from a coding/billing point of view) Even if it is not covered or it's bundled, at least you have an internal account of procedure codes and how different payors are handling them, what your global w/o's are, etc. 
I think some practices don't want to bill for the refraction because if it gets denied as not a covered benefit, then they have to collect it from the patient along with a copayment and for some reason some docs hate asking for their rightful copayments. But hey, it is what it is. I don't like paying for fillings and xrays on top of my copayment, but I have to if I want teeth! There's alot to discuss within this topic and I'm glad to have found this resource!

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## chip anderson

Always remember that 95% of patients and customers judge a doctor's worth and whether or not to go back to him on how well they see through thier glasses.   Unless one needs medicine, or surgery it doesn't make a bit of difference to the patient if one is the greatest at medicine or surgery in the world.     The patient is coming in for a refraction and a pair of glasses, patient is probably totally unimpressed with a "medical eye exam" no matter how thorough if nothing of significant medical importance is found.  
And no I hope I am not encouraging doctors to invent something of "significant medical importance" to impress the patient.  
However in defense of the above I did have very experienced and competent ophthalmologist tell me once: " Patient's used to come in when they were afraid something was wrong, and if you told them there was no cause for concern, they were happy..    Now patient's come in and if you don't give them some sort of eye drops (even if they are useless placebo type) they go to another doctor."
Strange how society is evolving isn't it?

Chip

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## bwoz

> Always remember that 95% of patients and customers judge a doctor's worth and whether or not to go back to him on how well they see through thier glasses. Unless one needs medicine, or surgery it doesn't make a bit of difference to the patient if one is the greatest at medicine or surgery in the world. The patient is coming in for a refraction and a pair of glasses, patient is probably totally unimpressed with a "medical eye exam" no matter how thorough if nothing of significant medical importance is found. 
> And no I hope I am not encouraging doctors to invent something of "significant medical importance" to impress the patient. 
> However in defense of the above I did have very experienced and competent ophthalmologist tell me once: " Patient's used to come in when they were afraid something was wrong, and if you told them there was no cause for concern, they were happy.. Now patient's come in and if you don't give them some sort of eye drops (even if they are useless placebo type) they go to another doctor."
> Strange how society is evolving isn't it?
> 
> Chip


Yes,  some of the thought process out there is definitely scary.

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## rlr.consulting

Why does everyone continue to get so technical about this?

YES!!! In the doctor's Office a refraction is a separate code! But there are two ways of getting paid for it by Medicare.

1.) Medicare does not consider a refraction to be a separate procedure and you may include the charges in the cost of an exam! (If you don't believe me contact me via my website for further discussion www.rlrbillingsolutions.com/contact.html)

2.) If you are more comfortable documenting the procedure you may bill medicare for it separately on the claim, however it will not be paid and if you call in for an explanation they will tell you exactly what I just said in #1. So, when following example #2 your best bet is to charge the patient for this up front and report it on the claim as paid in cash. This will then count toward the patient's deductible! 

Again, if anyone would like to talk to me about this in more detail, please contact me through my website http://optometricbilling.rlrbillings...ontact-us.html. I am a professional medical biller specializing in Optometric Billing and I would be more than happy to share with you any information that I have or just offer answers to some questions you may have.

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## bwoz

I believe Doctors have a valid reason to be concerned about the rules and regs of their billing because the industry is constantly changing. Unfortunately things are not always presented as cut and dry. To further complicate things, there are the specific LCD's of all other payors they are in contract with. Then that is sometimes sub-categorized when routine benefits (and now sometimes medical vision) are carved out to yet another payor. And in the end, they must be coding/billing/charging the same for all or be concerned that they might violate Starks Law/Anti Kick-Back, etc. Unfortunately, I haven't seen any documentation regarding what you're explaining. I'd love to see the links, though. For Medicare specifically, our carrier's Ophthalmology/Optometry Billing Guide from April 2008 states "...Expenses for all refractive procedures,...are excluded from coverage." We bill with appropriate mod's to receive official adj to then be able to charge the pt or forward to the secondary. I don't see how we can't be technical when billing for this specialty. 

barb

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## rlr.consulting

Barb,
    You are absolutely correct! Doctors do and should have a valid reason to be concerned. However with medicare, the more concern you have the more confusing it is. Yes the billing guide does state it is included from coverage but what it doesn't tell you is that it is excluded from separate coverage because the refraction is considered "to be part of a routine eye exam". This means that you can adjust the cost of an exam when billing to include the refraction when filing a claim.

Ex: 

Cash Patient:92004= $80.00
                    92015= $35.00

Medicare Claim: 92004= $115.00

(contact me at www.rlrbillingsolutions.com/contact.html for more info.)

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## bwoz

I understand completely what you are explaining. We do this with some carriers that spell out specifically that the refraction is included in the eye or E/M code.  Of course we then make sure that the payors that receive their claims with it split,  have the fees adj accordingly also.  My concern is that I have not seen any documentation supporting the statement that Medicare deems the refraction included in the office visit. Just that it's excluded. I'm not saying it isn't out there, just haven't seen anything like that and honestly none of the clients I have (that keep on top of these things) have mentioned that either. And these OD's are aware of the examples you have described. Any links for this CMS regulation you're talking about? I'd like to be able to research it.

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## drk

Barb: I appreciate the kindness.  People like you are the high priestesses of third party management, and your knowledge is like gold.

RLR: Are you saying that if our U&C ophthalmological code is X and our U&C refraction is Y, we can simply submit a ophthalmological code to MC as X + Y on a case-by-case basis?

Or, are you saying, in essence, that we can set our U&C ophthalmological code high enough to regularly include refraction, and just submit the the ophthalmolgical code and be content with the reimbursement for the exam only?

Thanks for your insight, RLR.

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## bwoz

> Barb: I appreciate the kindness. People like you are the high priestesses of third party management, and your knowledge is like gold...


Well thank you ever so much. This actually means alot as I am having a particularly difficult time trying to help a new client understand this exact situation. :o

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## orangezero

I'd still like to see some type of written explanation (from a medicare carrier) that explains this issue you are discussing.

If we can somehow bill medicare to include the refraction fee toward a patient's deductible, I'm all for that.  I just have never, ever seen it this way.

It doesn't really seem to jive with virtually all the other authorities I've ever read on the topic.

I would think if you included it in with the exam (for medicare) then the 20% the secondaries pay would be different.  This could cause problems.

Still, refraction is something that is confusing to explain to staff and patients.  Its a pain overall.

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## bwoz

I guess fee schedule's could be set to reflect the refraction on exam codes, and just not bill the refraction separately. But then wouldn't that need to be done for all payors? Is it then even allowed for every payor? If not, aren't you just back to square one regarding bundling this code? And also, how would that jive regarding an audit and *under*coding since you're not reporting a code that you are documenting if you actually perform the refraction?  :Eek:  Billing in this specialty is becoming very complex and half the time I don't think the Provider relations reps have any idea what I'm asking when I question their own guidelines.

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## nicker

Yeah, right!  I'm not calling anyone a liar, but if you were to call an insurance company and asked them how to bill, they will tell you it's your job to know.  They are NOT allowed to tell you how to bill. Sounds like your last inusurance person was making up her own rules.  
BTW, I bill it separately.  If you bundle it, you'll have a huge write-off-want to know why?  They'll say you're billing too much for an exam that doesn't even have a refraction. HAAA

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