How do we determine medical vs vision? 'We' do not - the examination does. The final codes related to any examination are derived from the chief complaint as well as the examination findings. Therefore, final codes cannot be assessed until after the examination is complete unless we know of a medical condition or medical chief complaint ahead of time.
Example medical exam #1: Known diabetic: these patients require a medical examination to ascertain the existence of diabetic retinopathy and at what level. These patients require more time, more coding, more paperwork, and also are a higher-level liability to the practice. Diabetes is the #1 cause of permanent vision loss in the US; therefore, we do not cut corners and spend the appropriate amount of time and resources on these patients.
Example medical exam #2: No known medical conditions; however, a significant medical issue is found during the exam which requires immediate attention. Incidental medical issues found which are unrelated to the chief complaint such as iris nevus, arcus senilis, visually-insignificant cataracts, pinguecula, etc do not need immediate attention, treatment, or education and therefore do not fall under this category.
Example 1: During a routine vision exam, we find a giant retinal detachment or significant retinal bleeding that must be documented, photographed, and referred to a retinal surgeon. This new code "retinal detachment" or "retinal hemorrhage" will override any vision codes as the primary diagnosis. Some vision insurances will not pay for the exam at this point unfortunately such as EyeMed. VSP however does allow for "Coordinated Billing" or COB.
Example 2: During the initial part of the exam, a patient complains of itchy eyes, dry eyes, flashing lights, or some other medically-related issue that they would like the doctor to evaluate and treat. At this point, the examination becomes medical due to the chief complaint and hence, the primary diagnosis.
Example medical exam #3: The patient comes in for a 'routine' vision exam, but in the chair complains of multiple medical issues that they would liek the doctor to evaluate and treat.
Example 1: "I'm here for my eye exam, but I've been having terrible headaches and my eyes have been very dry and red in the morning."
Example 2: "I'm here for my eye exam, but I've been seeing a lof of floating spots in my left eye for about 3 weeks now."
If you know you have a medical condition that we must evaluate and treat you have 3 options:
Option 1: Perform a medical exam and vision exam on the same day.
For those using VSP vision insurance, this is easy and is called "Coordinated Billing" or COB. VSP allows for COB and they make it easy and simple.
For those using EyeMed vision insurance which does NOT allow for COB in most cases, you will have to pay for the refraction up front and then submit your own paperwork to try and get reimbursement. This is due to their policy, not our's.
Option 2: Perform medical exam on one day and vision exam on another day. This of course requires 2 copays and days off from work - not ideal, but it is an option that some choose.
Option 3: Be referred to a specialist for the medical exam and come to us only for the vision exam AFTER the medical exam is performed. This requires extensive and ongoing communications between our office and the specialist office. This of course requires 2 copays and days off from work - not ideal, but it is an option that some choose.
Why can't the doctor just code my exam as vision to save me money? This is a type of insurance fraud in which our office does not participate. We bill appropriately according to the chief complaint, examination findings, and primary diagnosis.
Vision insurance is NOT "eye" insurance. We accept both vision insurance for routine, healthy checks but also medical insurance for those with either 1) known medical issues or 2) if there is a significant medical issue found during the examination that takes precedent over your chief complaint.