Skip to Content

Medicare

All charges are to be entered in the patient’s ledger on the day of services, regardless of whether the patient or insurance will pay. The patient’s vision or medical insurance may affect the amount the patient will pay at the time of their visit to the Clinic. The financial class field on the patient’s computer record should reflect the patient’s insurance and, in some instances, the Billing Department will append an insurance screen to the patient screen in the computer.

At the beginning of the year, Medicare patients have a deductible that they must meet, so the patient must pay for the exam in full at the time of services. Otherwise, we will not know if visit is covered until claim is submitted.

Medicare charges are entered into the patient ledger at the time of the visit. Medicare will cover Comprehensive codes (92___) and E/M Codes (99___) for a MEDICAL primary diagnosis ONLY. Medicare patients must have a medical (non-refractive) diagnosis or they must pay in full. Medicare will NOT cover a refractive diagnosis. Patients coming for refraction only (such as for post-cataract surgery) must pay a refraction fee of $29.00.

When coding your exam, be sure that:

  • Your chief complaint is medical in nature (i.e. Dry eyes, burning, blurry vision IF cataracts are found).
  • Your first diagnostic code is a medical diagnosis. DO NOT alter this code or it’s wording in any way. If you have additional comments, put them in the assessment/plan.
  • Examination is entered as Comprehensive Exam – w/o refraction – $101.00. Patient is responsible for 20% or $20.20; Refraction is $10 and not covered by Medicare.

With Medicare/Medi-Cal combined coverage, Medicare pays 80% of the approved charges. Medi-Cal pays the balance (up to the Medical-approved allowance.) Following cataract surgery, there is a small eyeglass benefit that Medicare will cover (one pair of glasses per lifetime).

FYI: Despite the fact that here at UCBSO we do charge separately for the refraction (92015), it should actually be billed separately and the patient should be paying for that out of pocket separately. Medicare does not pay for the refractive portion of the eye examination and will not pay for the examination at all if the diagnosis is refractive only.