Section OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE Section OPTOMETRY

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					Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE



Section 9: OPTOMETRY PAYMENT SCHEDULE
           AND BILLING GUIDE


Section Contents

          9.1     Optometry Payment Schedule ..................................................................... 9-2

          9.2     Optometry Billing Guide ............................................................................... 9-4
                  Diagnostic Codes and Note Records .............................................................. 9-5
                       Diagnostic Codes.................................................................................... 9-5
                       Note Records .......................................................................................... 9-5
                  Examination Frequency Checks...................................................................... 9-6
                      (1) Teleplan Eligibility Checks ............................................................... 9-6
                      (2) Practitioner Info Line ........................................................................ 9-6
                  Lens Prescriptions ........................................................................................... 9-7
                  Non-Insured Optometry Services .................................................................... 9-8
                  Payment Rules ................................................................................................ 9-9
                  Screening Eye Examinations......................................................................... 9-10
                  New Information for Optometrists.................................................................. 9-11
                  Medically Required Diagnostic Codes........................................................... 9-13


          9.3     Allowable Referrals ..................................................................................... 9-15




                           Page numbering in this document does not correspond to
                       that in the published Medical Services Plan Resource Manual for
                    Supplementary Benefit Practitioners. Updates to the document have been
                           made to reflect the changes to eye examination benefits.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE




9.1      Optometry Payment Schedule


                                       Optometry Payment Schedule

           Fee Item                              Description                        Fee Amount

            02899            Full optometric diagnostic examination of the eyes,      $44.83
                             including the determination of the refractive status
                             of the eye, the presence of any observed
                             abnormality in the visual system, all necessary
                             tests connected thereto, and the provision of
                             a written prescription if lenses are required.
                             Fee item 02899 is not billable in addition to fee
                             item 02892 when the patient is referred for low
                             vision assessment.

            02898            Re-examination or minor examination.                     $21.64

            02897            Repeat tonometry.                                        $10.40

            02892            Examination for low vision aid.                          $40.33
                             Fee item 02892 is billable only by optometrists
                             who have the appropriate equipment.
                             Fee item 02899 is not billable in addition to fee
                             item 02892 when the patient is referred for low
                             vision assessment.

            02893            Computer-assisted quantitative visual fields             $31.78
                             assessment.
                             Fee item 02893 is billable only by optometrists
                             who have the appropriate computerized
                             equipment for quantitative perimetry examinations.
                             The claim must specify the reason for the visual
                             fields examination.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE




            Fee Item              Contact Lenses Fitting for Keratoconus              Fee Amount

              02894           Contact lens fitting for keratoconus: unilateral.         $213.95

              02895           Contact lens fitting for keratoconus: bilateral.          $322.72

            Fee items 02894 and 02895 are billable only for patients with keratoconus who are
            unable to achieve 20/40 visual acuity with conventional glasses. The fee includes all
            visits and services necessary for fitting and follow-up for three months.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE




9.2      Optometry Billing Guide

         Section 9.2 contains general optometry billing rules.

         The topics are presented in alphabetical order. Refer to the Section Contents for
         Section 9.2 to find a particular topic.




            For additional billing information, see also:

                  Section 5.5:          Office Operations
                  Section 5.6:          Guidelines for Billing for Other Agencies
                  Section 6.1:          General Billing Information
                  Section 9.1:          Optometry Payment Schedule




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


         Diagnostic Codes and Note Records

         Diagnostic Codes

         On MSP claims, it is mandatory to specify the appropriate International
         Classification of Diseases, 9th Edition (ICD9) code for each service billed.

         Although the ICD9 code field accommodates a 5-digit code, some software vendors
         accommodate only the 3-digit minimum requirement in this field. However, claims
         that use 4-digit and 5-digit codes are normally processed more quickly and with
         greater accuracy because they provide MSP with more detailed information about
         the patient's condition.

         See Diagnostic Codes Considered Medically Required for Eye Examinations later in
         this section for a list of acceptable ICD9 codes and their associated frequency
         timelines.

         Note Records

         A note record is required when submitting a claim for an eye examination that
         occurs sooner than permitted by the Diagnostic Codes considered Medically
         Required for Eye Examinations.

         The guidelines apply to the most frequently submitted ICD9 codes, and may
         not include all conditions that meet MSP criteria for medically required eye
         examinations.

         A note record is not required when using codes from the list of medically required
         diagnostic codes if the eye examination occurred within the suggested frequency
         guideline.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


         Examination Frequency Checks

         The following MSP services assist optometry offices to determine the date of a
         patient’s last MSP insured eye examination;

         (1)   Teleplan Eligibility Checks

               The Eligibility Check functions provided by Teleplan enable you to verify
               immediately or overnight the date of a patient's last MSP insured eye
               examination. To request this information, enter E in the Patient Status Request
               field.


                  See also:      Section 5.2: Claims Processing - Benefits of Using Teleplan



         (2)   Practitioner Information Line

               If you do not submit claims electronically, you can call the Practitioner
               Information Line to inquire about the date of a patient’s last MSP insured eye
               examination using interactive voice response (IVR).


                                               Practitioner Info Line (IVR only)

                    Victoria phone:                 250-383-1226
                                                    250-952-3102
                    Vancouver phone:                604-669-6667
                    Toll-free phone:                1-800-742-6165




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


          Lens Prescriptions

         Claims submitted under fee item 02899 (full optometric diagnostic examination)
         must include providing the patient with a written prescription for corrective lenses if
         required.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


         Non-Insured Optometry Services

         The following eye-care services are not covered by MSP but may be covered by the
         patient's private extended health care insurer:

             • routine eye examination for patients ages 19 to 64
             • external ocular photography
             • internal ocular photography
             •   contact lens fitting other than for keratoconus as specified in Payment
                 Schedule
             • spectacle treatment services
             • vision training or vision therapy (orthoptics)
             • visual fields tests not as specified by MSP
             • corneal topography
             • contrast sensitivity
             • electro-diagnostic procedures
             • quantitative colour-vision testing
             • punctual occlusion procedures
             •   services provided subsequent to other services not covered by MSP
                 (eg., photo-refractive keratectomy - PRK)
             • third party-initiated eye examinations
             • services required as a condition of employment
             • services pertaining to work-related injuries covered by WCB
             • verification of prescriptions filled out of office
             • examination or services for a second opinion
             • completion of forms, reports, letters, etc.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


         Payment Rules

         The following rules apply to optometry claims:

             •    Fee items 02894 and 02895 (contact lens fitting for keratoconus) include
                  fee items 02898 (re-examination or minor examination) and 02899
                  (full optometric diagnostic examination) when provided by the same
                  optometrist seven days prior to, and three months following, the first fitting.

             •    Fee item 02897 (repeat tonometry) is included in fee items 02898
                  (re-examination or minor examination) and fee item 02899 (full diagnostic
                  examination) when provided on the same date of service.

             •    MSP recognizes a referral by an optometrist to an ophthalmologist for
                  consultation and continuing care.

              •   For patients between 19 and 64 years of age, only medically required eye
                  examinations may be billed to MSP.



                  See New Information for Optometrists And Diagnostic Codes Considered
                  Medically Required for Eye Examinations later in this section for guidelines.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


         Screening Eye Examinations

         Eye examinations for the purpose of screening school-aged children is not a benefit
         of MSP. Examinations for this purpose should be billed directly to the parent or
         guardian of the child, unless there is another funding agreement in place.




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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


New Information for Optometrists

Effective November 19, 2001, “routine” eye examinations are no longer a benefit of the
Medical Services Plan for patient’s 19-64 years of age. This change applies to services
provided by both optometrists and ophthalmologists.

The following should clarify when a service is considered medically required:

A routine eye examination is not a benefit for individual ages 19-64 when not associated with
an ocular or systemic disease or condition, trauma or injury or if the patient is using a
medication which could reasonably be expected to cause a change in refractive status.
Exceptional circumstances may be given independent consideration when supported by
documentation.

An eye examination will still be an insured service if medically required. Medically required
eye examinations may be a benefit for the following conditions:

•   ocular disease, trauma or injury
•   systemic diseases associated with significant ocular risk (e.g. diabetes)
•   medications associated with significant ocular risk

When billing eye examinations it isn’t always necessary to include a note record as the ICD9
describes the reason for the eye examination. However, if there is an exception to the
frequency rules the medical indication must be provided in the note record and those claims
will be given independent consideration. When reviewing the following frequency guidelines
please note that there are some exceptions to the 12 month frequency rules:

•   Any variation of other retinal disorders (ICD9 362) is payable once every 12 months
    except when billed with ICD9’s 3620, 36201 and 36202, which are payable every 6
    months
•   Glaucoma (ICD9 365) is paid every 12 months unless billed with a note record indicating
    “severe or uncontrolled glaucoma” and then it is paid every 6 months.

Please note, services for conditions not listed on the attached frequency guidelines are
the responsibility of the patient unless an examination by an optometrist is requested
directly by the general practitioner.

In cases such as a headache where in your judgement and based on clinical evidence, your
patient may be suffering from an ocular problem that is not refractory in nature, MSP will
consider accepting the eye examination as medically required. The service would need to be
billed with the appropriate diagnostic code or note record. However, if your patient presents
with a headache and there is no medical problem, the eye examination would not be a benefit
of MSP. Your patient should be advised that they would be responsible for the cost of the eye
examination unless a condition that meets the criteria of “medically required” is discovered.


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Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE


Also, an eye examination based on family history alone is considered “screening” and would
not be a benefit of MSP. However, if your patient, based on symptoms and family history is at
“high risk”, the resulting service would be a benefit of MSP.

Post-operative care during the six-week post-operative period by the surgeon or surgeon’s
associate is considered included in the surgical fee unless otherwise indicated in the MSC
Payment Schedule. Following the eye surgery and after the six week post operative period, the
surgeon may bill one eye examination when medically indicated. MSP recognizes the
importance of co-management of patients who live in rural areas where no ophthalmologist is
available. Therefore, in these cases, MSP will pay fee item 02899 to an optometrist in the
patient’s community following eye surgery, whether or not the service is rendered within the
six-week post-operative period.

Eye Examinations for Eligible First Nations Clients

The Non-Insured Health Benefits Program of the First Nations and Inuit Health Board will be
covering the cost of routine eye examinations every 24 months for eligible First Nations
clients between the ages of 19 and 64 that have valid Medical Services Plan coverage. Prior
approval must be obtained for claims to be processed. All prior approval requests and claims
should be faxed to 1 888 299-9222.

As MSP gains experience with this new policy, further communication will be published to
assist you with explaining this policy to your patients.




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Diagnostic Codes Considered Medically Required for Eye Examinations
The following diagnoses are considered medically required, and eye examinations are payable at the
frequency indicated. A note record documenting the medical necessity must be included to support
exceptions to these frequencies.

Services for conditions not listed below are the responsibility of the patient unless a referral is medically
indicated and provided to the ophthalmologist directly by the referring physician.

Please note, under each three digit diagnostic code – the four and five digit codes in the same category
would be limited to the same frequency guidelines. The exceptions are listed below (3620, 36201 and
36202).

Eye examinations billed with the following diagnostic codes are payable once every 24 months:

360              Disorders of the globe
363              Chorioretinal inflammations, scars and other disorders of choroid
368              Visual disturbances
369              Blindness and low vision
375              Disorders of lacrimal system
379              Other disorders of eye
4019             Hypertensive disease not specified as malignant or benign
05440            Herpes simplex – ophthalmic (acute onset)
05320            Herpes zoster – ophthalmic (acute onset)
94010            Burns of eyelids and periocular area
92190            Unspecified contusion of eye
9182             Superficial injury - conjunctiva
9301             Foreign body in conjunctival sac
9181             Superficial injury - cornea
9300             Corneal foreign body
8026             Fracture – orbital floor (blow out), closed
9502             Injury to optic pathways
9503             Injury to visual cortex
99520            Unspecified adverse effect of drug, medicament and biological
                 (allergic reaction to medication)

Eye examinations billed with the following diagnostic codes are payable once every 12 months:
361              Retinal detachments and defects
362              Other retinal disorders
364              Disorders of iris and ciliary body
365              Glaucoma
366              Cataract
370              Keratitis
371              Corneal opacity and other disorders of cornea
372              Disorders of conjunctiva
373              Inflammation of eyelids
374              Other disorders of eyelids
376              Disorders of the orbit
377              Disorders of optic nerve and visual pathways
378              Strabismus and other disorders of binocular eye movements
27910            Deficiency of cell mediated immunity (AIDS (HIV))
7200             Ankylosing Spondylitis
43600            Cerebrovascular disease – acute but ill defined
17400            Malignant neoplasm of breast
16200            Malignant neoplasm of trachea, bronchus and lung
34000         Multiple sclerosis
35800         Myasthenia Gravis
23700         Neoplasm - pituitary gland and craniopharyngeal duct
13500         Sarcoidosis
24000         Goitre, specified as simple
71020         Sicca Syndrome (Sjogren’s Syndrome)
71000         Systemic Lupus Erythematosus
44650         Giant Cell Arteritis (Temporal Arteritis)
224           Benign neoplasm of eye
8717          Unspecified ocular penetration
E07           Intraocular surgery or injury with penetrating wound
9404          Burn – Cornea / Conjunctiva
V6751         Following high risk medications ***
              ***Claims with this code must be accompanied by a note stating type of medication.

Eye examinations billed with the following diagnostic codes are payable once every 6 months:
250           Diabetes Mellitus
3620          Diabetic Retinopathy
36201         Background diabetic retinopathy
36202         Proliferative diabetic retinopathy
Section 9: OPTOMETRY PAYMENT SCHEDULE AND BILLING GUIDE




9.3        Allowable Referrals
            This table indicates when supplementary benefit practitioners are able to make
            referrals to other specialists.




                  Referring
                Supplementary         Referring
                   Benefit            Specialty
                 Practitioner          Code           X-Rays         Labs         Consultation and Continuing Care

              Chiropractor                30             No           No        Orthopaedic Surgeons only.

              Naturopath                  31             No           No        No

              Physical Therapist          32             No           No        No

              Osteopath                   34            Yes           Yes       Yes

              Podiatrist                  38            Yes1         Yes2       No

              Optometrist                 39             No           No        Ophthalmology Consultation (02010,
                                                                                02011 - continuing care fee items). May
                                                                                also refer to general practitioner.

              Massage Therapist           43             No           No        No

              Oral Surgeon                37            Yes3          Yes       Yes: diagnosis must relate to problems
                                                                                with mouth or mastication.

              Dental Surgeon              40            Yes           Yes       Yes: diagnosis must relate to problems
                                                                                with mouth or mastication.

              Orthodontist                42            Yes           Yes       Physical therapists and massage
                                                                                therapists only when relating to mouth
                                                                                and mastication problems.




  1   The X-rays "Yes" for Podiatrists applies only to x-rays associated with remedying disorders of the feet.

  2   The Labs "Yes" for Podiatrists applies only to lab tests associated with remedying disorders of the feet.

  3The X-Rays "Yes" for Oral Surgeons, Dental Surgeons, and Orthodontists applies only to diagnostic x-rays, not to
   imaging.
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