Patient intake coding for medical diagnoses

January 23, 2024
Patients often find medical plan and vision care plan coverage to be confusing. Take these steps to ensure patients are fully aware when their medical plan may be billed.
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Written by the AOA’s Coding & Reimbursement Committee. Excerpted from page 44 of the December 2023 edition of AOA Focus.

As doctors of optometry know well, patients often find medical plan and vision care plan coverage to be confusing. A survey published in June by the Kaiser Family Foundation, an independent source for health policy research, polling and journalism, found that about half of insured adults report some difficulty understanding at least one aspect of their plan, such as what their medical plan will cover, what they will owe out of pocket for care or what their explanation of benefits statement means. This lack of understanding creates real challenges and can lead to delays in obtaining necessary care.

The difference between medical plan and vision plan coverage can be especially confusing to patients. The ability of front-office staff to explain the difference adequately and accurately between “vision-” and “medical-” related eye problems (and which plan will be billed) is of extreme importance. Ensuring the patient intake form clearly outlines situations in which the patient’s medical plan will be billed adheres to the principles and ethics of transparency and can help alleviate the patient’s confusion.

Medical plan or vision care plan: Who gets the bill?

The answer lies with the patient’s history and the patient’s reason for coming in to be seen. If the patient does not have a chief complaint, or if the reason for the visit is refractive in nature, the doctor of optometry should bill the patient’s vision plan.

However, if the patient has a chief complaint beyond a refractive issue and/or has a medical issue related to ocular health, the doctor of optometry should bill the patient’s medical plan. The medical plan should be billed for any required testing and follow-up appointments needed to address the ocular health issues.

To ensure that patients are fully aware when their medical plan may be billed, doctors of optometry should consider including language on their standard patient intake form that clearly and effectively communicates that any medical services that are provided as a result of ocular complaints or from conditions discovered during the comprehensive eye examination will not be billed to the patient’s vision plan but to their medical plan. Clear and concise communication between the practice and any patient is vital. The AOA suggests language akin to the following:

During the performance of a comprehensive eye examination, certain medical eye conditions may be revealed that deserve special attention. I understand that there are specific coverage limitations with my vision care plan and that (practice name’s) contract with the vision care plan does not cover medical eye care services. In this event, my medical plan will be billed, and I understand I will be responsible for any applicable copays, cost-shares and/or deductibles. I also understand that (practice name) will not neglect medical findings to bill my vision plan, as that would put (practice name) in direct conflict with its ethical obligations to the (State Board of Optometry).

Of utmost importance, however, is that doctors of optometry should ensure that their policies and documentation are in line with contractual obligations they have with medical and vision plans, respectively, and doctors should consult with their attorney before using the above language. Further, doctors should be fully versed on the applicable state and federal laws that regulate the practice of optometry.

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