Serious conditions discovered during a routine exam often requires a referral


Billing for a routine exam which uncovers a serious medical problem must be handled on a case-by-case basis.

Key Points

Our ophthalmology practice employs physicians as well as optometrists, who generally provide routine vision exams. We've long debated the correct way to bill for services in which the routine exam uncovers a serious medical problem that will ultimately require a referral to a specialist-particularly since some insurers won't reimburse for services provided by optometrists. What would you advise?

The situation you describe requires a case-by-case decision: The severity of the medical condition, the patient's insurance coverage, and the skill of the provider doing the initial evaluation are among the factors to consider. The easiest solution: When a routine vision exam results in a medical diagnosis, submit the visit with the vision examination codes 92002-92014, listing the preventive V code as the primary diagnosis and the medical condition as the secondary diagnosis. To bill for services provided by the specialist based on the optometrist's referral, use E&M codes 99212-99245, as appropriate, and submit the medical diagnosis with the claim.

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