One of the most performed ophthalmic diagnostic tests is the refraction. Some level of refractometry is likely performed at most eye exams.

Of course, a detailed refraction is required to provide an eyeglass or contact lens prescription to the patient. In addition, the test is often performed to determine the best corrected acuity when surgery is being planned or to determine if a recent decrease in vision is due to a refractive change or a medical issue.

A frequent question is, “When is a refraction billable?”

Performing a refraction

Clinically, refraction means determination of the eyes’ refractive error and prescribing the appropriate corrective lenses. For patients capable of responding to choices, a refraction is accomplished by presenting the patient with a series of test lenses in graded powers to determine which lenses provide the sharpest, clearest vision.

For young patients (less than 6 years of age) who cannot give a subjective reply, retinoscopy, an objective measurement of refractive error, requiring little or no patient response, is the key to refraction.

After the measurements are made, the ophthalmologist or optometrist decides on the appropriate prescription.

Providing a prescription

In 1978, the Federal Trade Commission created the Eyeglass Rule in response to complaints that some ophthalmologists and optometrists would not provide a valid prescription to patients who wished to buy eyeglasses elsewhere.

This longstanding rule “…requires an eye care practitioner to provide a patient, immediately after completion of an eye examination, with a free copy of his or her eyeglass prescription. The Ophthalmic Practice Rules also prohibit an eye care practitioner from conditioning the availability of an eye examination on a requirement that the patient agree to purchase ophthalmic goods from the practitioner.”

Note, the Rule does not require the patient ask for a prescription — the ophthalmologist or optometrist must provide it anyway — as long as the prescription is accurate and complete.

Charging for complete refractions

This FTC rule means a refraction is necessarily accompanied by an eyeglass prescription, otherwise it isn’t complete. As a practical matter, charge for a refraction — particularly when the patient has to pay — only when a refraction is completed and a prescription given.

Incomplete services

A refraction is incomplete when it is:

• Tentative (eg, only spherical equivalent)
• Incomplete (eg, unrefined or omit some element)
• Unreliable (eg, unstable diabetic, elevated BS)
• No verifiable endpoint (ie, inconclusive)
• Only refractometry by a technician (eg, no Rx)
• Only autorefraction (eg, preliminary only)

If no prescription is given, then a charge for the refraction should not be made.

Frequency of repeated refractions

Repeat refractions are based on the patient’s needs. The following conditions or circumstances support the need to repeat a refraction:

• Glasses or CLs are unsatisfactory
• Unexplained change in vision
• Visual acuity can be improved
• Complaint of poor vision or visual discomfort
• The prior refraction is no longer reliable.

Coding for refractions

For coding and claim submission, there are several ways to report refraction. CPT 92015 is used in addition to the code for the accompanying eye exam.

In other cases, where the exam and refraction are packaged as a single service, HCPCS codes S0620 and S0621 (Routine ophthalmological examination, including refraction) are used to report the combination for new and established patients, respectively. “Routine ophthalmological examination” means the exam does not cope with disease, illness, or injury; therefore, the diagnosis should be myopia, hyperopia, astigmatism, presbyopia, or some combination of these diagnoses.

Collecting payment

Traditional Part B Medicare never covers refractions. Stand your ground with patients who argue refractions will be paid by Medicare when performed in conjunction with a medical condition (eg, monitoring keratoconus or planning cataract surgery). They will not.

All other third-party payers, including Medicare Advantage plans, set their own policies. In considering a your collection policy, keep in mind the following:

• Part B Medicare: Payment is due at the time the service was rendered — it’s noncovered
• Part C Medicare: May be covered if a vision benefit was added to basic Part B coverage
• Medicaid: Refraction is often covered — file a claim
• Vision plan: Refraction is covered — file a claim
• Medical plan: Refraction is rarely covered — payment is due at the time of service.

Claim completion

Use CPT 92015, with the appropriate modifiers, when needed, on insurance claims to report the service and obtain a response about coverage from the payer. This also provides patients with clarity of their financial responsibility. The modifiers:

• 92015-GX. When a refraction is not covered and the ABN was voluntarily given (Medicare, gave ABN)
• 92015-GY. When a refraction is not covered and no ABN was given (Medicare, no ABN)
• 92015-GA. When a refraction is probably not covered and a waiver was given. Since this does not apply to Medicare Part B, the ABN form provided by CMS cannot be used.

Conclusion

A refraction is a useful and valuable test. A charge for a final refraction is valid as long as it is complete, accurate, and a prescription given.

It is important to distinguish between complete and incomplete refractions. The FTC’s rule requires ophthalmologists and optometrists to provide a prescription to the patient, even if the patient does not request it, for a valid, accurate, and complete refraction.

Also, know the policy of the payer involved. For Part B Medicare patients, the rules are very clear. Refraction is never covered — it is the financial responsibility of the patient or other secondary insurance plan. For all other payers, follow their instructions. OP

Ms. Johnson is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.