Typically your Primary Care Physician would provide these services.
Vision screening is a brief evaluation (such as with a Snellen – or “big E” – chart) and can be performed by a primary care doctor as part of a regular physical. A vision screening does not diagnose or correct vision or eye health issues. This is not the same as a routine or comprehensive vision and/or eye examination.
Routine Vision Services
Routine vision care is the examination of the eyes, with or without dilation, to determine the health of the eyes and related structures, visual acuity, and determination of the patient’s refractive state, prescribing corrective lenses if necessary. In simple terms, eye care professionals, Optometrists or Ophthalmologists, who have specialized diagnostic equipment, check vision, screen for disease, and update prescriptions for eyewear.
Routine vision care coverage includes a comprehensive eye exam. Depending on plan design, it may also provide coverage for hardware (frames, lenses and contact lenses).
In some cases, a routine vision exam can transition to a medical eye exam if during the course of the examination the eye care professional discovers a condition that requires additional testing or a special diagnostic procedure.
Medical Eye Care
Medical eye care is the examination, treatment and management of an eye condition or disease, such as cataracts, glaucoma, diabetic retinopathy, macular degeneration, infections, eye pain or injury.
Individuals with confirmed and/or suspected medical eye diseases receive covered benefits for the management and treatments of these diseases within their medical coverage.
When it comes to insurance, it is very difficult to get accurate and concise information from anyone. This includes your insurance company that sells you the insurance! You can talk to three insurance representatives and get three different answers. This is our attempt at bridging that gap.
IF YOUR EXAM DIAGNOSIS IS ANY OF THE FOLLOWING.
Any level of Cataracts, (including previous cataract surgery,) any form of Diabetes, Glaucoma/Glaucoma Suspicion, Ocular Hypertension, any form of retinal or Corneal Degeneration, Keratoconus, Corneal Dystrophy, Retinal Defects (including a history of retinal holes, breaks, tears and/or detachments,) or a history of any kind of ocular surgery or other specific neurological findings.
ANY OF THE ABOVE REQUIRES THE VISION CENTER TO BILL YOUR PRIMARY MEDICAL INSURANCE.
WHY THIS MATTERS TO YOU. (none of the following pertains to Medicaid)
Why are you billing my medical insurance? (Medicare, Anthem, Harvard Pilgrim, Cigna, United Health Care, ETC.)
With any of the above exam diagnosis, your insurance carriers have us bill against the primary medical insurance benefit. Any medical condition that can affect your vision is always of primary concern to your eye doctor.
How can I use my vision insurance if I have a medical condition?
There are a couple of ways to use your vision benefit.
The most popular way is for us to provide the entire exam in one visit. We would monitor/address your medical diagnosis. Bill your primary medical insurance and possibly coordinate the refraction with your vision insurance. Not all vision plans allow this process. Davis Vision never does, Eyemed rarely does, and Vision Service Plan or Cigna Vision usually does allow coordination. This is typically the most cost effective solution and time saving.
See us two times. We can do an office visit to monitor/address your medical diagnosis. Then a second visit just for routine vision. We ALWAYS do these exams in order of medical then routine.
Same as number 2, except the medical visit is with an ophthalmologist or specialist. They take responsibility for monitoring/managing any medical diagnosis and within six months of seeing them we can do the routine portion of the exam. Tell them your eye doctor will do the refraction!
I have a high deductible insurance can’t we just ignore the medical?
Treating patient’s differently to increase or decrease patient costs is considered insurance fraud. We bill all patients the same way regardless of their insurance or lack of insurance. Your primary diagnosis dictates how the insurance companies require us to submit the claim.
You’re “just” eye doctors you cannot be billing medical insurance!
Our doctors are considered specialists by all insurances. They are registered and trained in the diagnosis and treatment of the many medical conditions listed above. They are legally required to provide the appropriate level of care per the diagnosis.
Costs and General information
-With the above diagnosis your insurance carriers have us bill against the primary medical insurance benefit. Any medical condition that can affect your vision is always of primary concern to your eye doctor.
-Most medical insurances have high deductibles or a co-insurance. Typically, in the case of a high deductible, 70% to 100% of the “Billed to Insurance” balance on your receipt will come back to you in the mail.
-Our doctors are specialists, and as such, you can expect to pay the specialist copay. If your insurance requires a referral, please check with the staff to ensure that we have received one. (Or have one in the works.)
Procedure codes and what they mean:
1. 92004-92014 ($120-$150) or 99203-99215 ($75-$195) The comprehensive eye exam (codes starting with 92) is an Important part of preventative health care performed by a Doctor of Optometry. It can be likened to a physical for the eye because it looks at the entire eye and visual system. Codes starting with 99 are used for office visits or consultations. This exam procedure is used for emergency visits or follow up appointments including any glaucoma testing.
2. 92015 = ($55) This is a refraction code. It’s the part of an eye exam to measure a person's prescription for eyeglasses, contact lenses, or to figure out how well you can see. Insurance requires this to be billed as a separate procedure. All insurance companies consider this to be a routine service. Medicare has no benefit towards routine services, including refraction. Other medical carriers, including Anthem/BCBS, UHC, Cigna, ETC., may have limited coverage for this service. In some cases it is be possible for your routine vision plan to cover this service after being denied by your medical insurance provider. (Most VSP Plans will help, but Davis Vision plans will not, and <2% of Eyemed plans will allow us to bill them for the refraction on your behalf.)
3. 92250 ($39-$85) This procedure is billed when taking photos of the back of the eye. These photos can give an accurate assessment of changes over time to your ocular health, including your optic nerve and blood. There is a medical photo and a basic photo that the instrument can take.
4. Contact lens Eval./Fit Train ($30-$160) This service is to evaluate the safety and fit of contact lenses on your eyes. It is charged when issuing a prescription for contact lenses.
5. Other tests can be required or requested by your provider. This will be in conjunction with monitoring certain medical conditions and only first billable to your primary medical insurance. Topography, OCT, Visual Fields, and a few other tests are not billable to your vision insurance, 99% of the time.