The CMS precedent-setting 2008 policy provided, for the first time, preventive services for patients with diabetes, including an eye exam.¹ Before, a patient had to have clinically evident signs and symptoms of ocular diabetic disease before Medicare would cover the exam. As of 2008, patients with diabetes, and in the absence of diabetic retinopathy, are allowed a comprehensive dilated eye exam on an annual basis.² Subsequently, many, if not most, commercial carriers have followed suit with similar policies.

A Policy Often Misunderstood 

With this shift, many felt that, irrespective of coverage, the medical carrier was always responsible for these exams. Many ODs rejoiced because they felt they could ignore the reduced reimbursement rate for a diabetes patient’s annual comprehensive eye exam—a national average of about $55 from a managed vision care plan—and instead bill the same exam at nearly triple the rate to the medical carrier.³ This, however, isn’t always the case.

The “diabetic eye exam” is a frequently discussed topic at optometric conferences. But I really don’t know why because no such thing exists. We can provide a comprehensive ophthalmic exam for a patient with diabetes in the absence of diabetic retinopathy using codes 920X4 as medical policy guidance provides. This, of course, is where the devil is in the details and where our ethics as providers come into play.

Who Foots the Bill? 

When a diabetes patient has both a managed vision care plan and a medical plan—both of which cover a comprehensive ophthalmic exam—it’s not our choice which coverage to use or who to bill. It is the patient’s choice. Most ODs want to bill the medical carrier because it’s a “diabetic eye exam,” not a managed vision care exam, and those plans don’t pay enough anyway. Most choose to bill the carrier that pays the most—not a good strategy when defending yourself on audit.

My understanding of the CPT rules is that services provided are defined by the CPT code used to describe and bill for them. Therefore, a 92004 is a 92004, regardless of who is billed. In fact, some managed vision care plans likely have 92004 definitions (and requirements) that are more detailed than those of Medicare and the CPT. Additionally, there is no such thing as medical 920X4. CMS’s requirements for preventive care related to a comprehensive ophthalmic exam require the patient to have a dilated fundus exam. This is not in alignment with HEDIS requirements that allow a fundus photo as a proxy. 

The pushback I receive from optometric peers is mostly based in remuneration, not logic—and that is not a good defense. If a patient has duplicative coverage and both of their carriers pay for a 920X4, we must inform the patient of this, provide accurate information regarding copays and out of pocket costs (i.e., refraction if billed to medical carrier) and let the patient make a well-informed decision of which policy to use. One caveat to keep in mind: some managed vision care plans do stipulate that they want you to bill the medical carrier and not the managed vision care plan in this circumstance, so keep up with your carrier contract requirements.

In the past, patients would usually choose to bill the managed vision care policy. But a decade of this policy has led to many medical carriers waiving the deductible or copay for a comprehensive ophthalmic exam for patients with diabetes and in the absence of diabetic retinopathy. The patient’s only out-of-pocket expense is the refraction (92015), which in many cases is similar to their managed vision care plan co-pay. 

With proper patient education, you can often get paid more for your services while following the rules. This allows you to provide the highest level of services and protects you and your practice from unwanted scrutiny from third-party carriers. No one wants to be in the crosshairs for doing the wrong thing.

Send your own coding questions and comments to  rocodingconnection@gmail.com.

1. Centers for Medicare and Medicaid Services (CMS). Medicare Coverge of Diabetes Supplies and Services. www.medicare.gov/Pubs/pdf/11022-Medicare-Diabetes-Coverage.pdf. November 2008. Accessed April 28, 2019.  2.CMS. An overview of Medicare covered diabetes supplies and services. MLN Matters. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0738.pdf. Accessed April 28, 2019.   3. CMS. Physician Fee Schedule. www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=0&H1=92004&M=5. Accessed April 29, 2019.