Has optometry shot itself in the foot again? Optometrists, in their ongoing drive to offer their professional refractive services to private pay patients for reduced prices, are now starting to feel the pain of their efforts.
Refractive insurance companies across the country are now starting to require O.D.s to use the routine eye examination codes—more specifically the S codes (S0620 and S0621)—when patients come in to utilize their vision benefits, instead of the traditional ophthalmic eye examination 920XX codes.
Of course, this requirement often carries reduced reimbursement for routine eye care compared to comprehensive care.
Race to Zero
How did this happen? Let me lay out some of the facts that got us here.
First and foremost, O.D.s have had difficulty in understanding the value of their intellectual property—their clinical skills and what they offer to the health care community.
Second, they’ve wanted to maximize their reimbursements from both medical and refractive insurance carriers for their services.
Third, they’ve wanted to reduce the cost for the same services to their private pay patients—what I often refer to as the “race to zero.” In other words, O.D.s simply have a hard time charging the uninsured patient the same price for a comprehensive eye exam and refraction as they’re willing to charge an insurance company.
The Double Whammy
Enter the S codes… Introduced in 2004, the S codes were the first within the Healthcare Common Procedure Coding System (HCPCS) to include refraction as part of a routine eye examination. The only trouble is that HCPCS provided no further detail in defining a routine eye exam compared to a comprehensive eye exam. The rules of the Current Procedural Terminology (CPT) dictate that these exams cannot be comprised of the same services or core components; therefore, they should be categorized as different levels of service.
Yet, many O.D.s saw the S codes as a solution (that is, a vehicle) to provide comprehensive eye examinations to private pay-patients at a reduced price. They made the mistake of providing the same set of services for a 920X4 and 92015 as an S062X.
Insurance carriers have since recognized this, and now they’re changing our primary refractive services covered by their contracts from 920XX codes to the S codes. For instance, VSP introduced the S codes last fall. More recently, Anthem Blue Cross in Kentucky notified Kentucky O.D.s that it is changing its codes in August 2011.
Because we have little to differentiate comprehensive care from routine care in our practices, insurers have found that our ignorance can work to their advantage. Eye examinations done for refractive purposes are widely discounted within the marketplace, they say. They want to take advantage of this so they’ve hit us with a double whammy—we’re required to both use the S codes and take significantly less reimbursement.
So here’s a question to ponder: What tests should we leave out of an eye examination done for the “purpose of refraction”? It’s my opinion that the S codes pose a significant risk to our profession since they’re not widely used outside of optometry. Their use could put optometrists into a position of violating their state law, HIPAA and CPT rules in general.
With legislative gains in scope of practice all over the country, optometrists play an ever-increasing role as members of the primary health care team. So, using S codes could pose many risks for our access to the full range of services we are licensed to provide.
Clinical Coding Committee
• John Rumpakis, O.D., M.B.A.,
Clinical Coding Editor
• Joe DeLoach, O.D.
• David Mills, O.D., M.B.A.
• Laurie Sorrenson, O.D.
• Rebecca Wartman, O.D.
Before you say yes to a plan that requires you to use the S codes, or if you are considering using them in your own practice, be prepared to ask yourself WTF—What’re the facts? Till next month…
