Coding and Billing

Examination Coding Clarification: Medical vs. Non-Medical vs. Routine

By Charles B. Brownlow, OD

Understand the difference in coding between medical, non-medical and routine examinations–and train your staff to understand these differences, as well. Then create corresponding office policy to guide coding.

Eye doctors and their key staff people are faced with the same challenge several times each day. Even though the content of patient records for many eye examinations looks pretty much the same, some of the visits must be considered “medical” and thus billed to the patient’s medical insurer, and some must be considered “routine” or “vision” or “non-medical,” and billed to the patient and/or the patient’s vision plan.

Coding and Billing Toolbox

The American Optometric Association offers resources to help you increase the efficiency of your coding and billing process.

The following medical records and coding resources are available through AOAExcel.

•    Medical records and coding webinars are provided as a no-cost AOA Member-Only benefit to educate doctors and staff on medical recording keeping and coding.

• is an AOA Member-Only benefit available to AOA members at no cost (previously $349). is a web-based resource for information related to procedure and diagnosis codes, national and local coverage rules and Medicare relative value information.

•   Codes for Optometry, is available in print and searchable CD formats from the AOA Order Department. This two-volume set includes Current Procedural Terminology from the American Medical Association, and a separate volume of diagnosis codes used in eyecare, Medicare’s Correct Coding Initiative, the HCPCS codes for reporting materials in Medicare, and the Documentation Guidelines for the Evaluation and Management Services.

•    Coming in 2013: An EHR & Medical Records Compliance Program.

Visit for integrated professional resources to improve patient quality of care, operational practice excellence and informed business decision-making.

For more information:

Recognize Examination Key Characteristics

Having looked at thousands of patient records created by hundreds of eye doctors, I have noticed some definite trends. First, a record for an eye examination will have many of the same characteristics, whether the examination was prompted by a medical reason, a refractive reason, or no reason at all, such as the patient who enters saying, ”It’s just time for an eye examination.” Each time we see a patient, it is important for them and for us that we do certain things to be sure we’re not missing a hidden eye problem or a hidden systemic health issue. In eyecare, there are great similarities from one record to another, whether the reason for visit is “medical” or “non-medical.”

Second, eye doctors tend to be very thorough in their data gathering through nearly every encounter. An outsider, such as an auditor, might remark, “It’s unusual to see such a detailed medical record for a patient with such a limited reason for a visit.” Auditors may not know that the health of the eyes is integral to the health of other organ systems, and that signs of medical conditions elsewhere in the body will often show up first in the eyes. Auditors may not know that, but eye doctors do, and that is why the examinations and records are as thorough as they are.

The records of case history, examination and medical decision making are pretty much the same across many patients that we see each day, so how can doctors and staff determine where the claim should be sent?  How should one decide whether a visit was “medical” or “non-medical”?

In eyecare, the doctor customizes the care provided at each visit to the needs of the patient that day. Often, some of what is done is non-medical, vision-related, and some is medical. Actually, the only reason we have to classify a visit as medical or non-medical is to determine who gets the bill. That is accomplished by going back to the beginning of the medical record and looking at the reason for the visit. The reason for the visit is the only real determinant of what is done during each patient visit and whether a visit is non-medical or medical.

Medicare’s Carrier’s Manual Explains:
“The coverage of services rendered by an ophthalmologist (or optometrist) is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to an ophthalmologist (or optometrist) with a complaint or symptoms of an eye disease or injury, the ophthalmologist’s (or optometrist’s) services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist (or optometrist) for an eye examination with no specific complaint, the expenses for the examination are not covered (by Medicare) even though as a result of such examination the doctor discovered a pathologic condition.

In the absence of evidence to the contrary, the carrier may assume that an eye examination performed by an ophthalmologist (or optometrist) on the basis of a complaint by the beneficiary or symptoms of an eye disease was not for the purpose of prescribing, fitting, or changing eyeglasses.”
Note:  Words in italics, “or optometrist” and “or optometrist’s” and “by Medicare” were added to the original language by the author of this article, but can be assumed to have been the intent of the policy’s original drafters.

Create Examination Classification Policy
If you haven’t already done so, this is a good time to create policy within your office to reflect long standing logic, the rules of Medicare and the language of many insurers’ provider agreements. Your policy might say something like, “If the doctor determines that a patient has entered the office for a medical reason, presenting problem, symptom, or complaint, the care that is provided is considered medical and will be billed to the patient and to the patient’s medical insurer. If the doctor determines that the patient has entered the office for a non-medical reason, without a medical problem, symptom, or complaint, the care is considered non-medical and is billed to the patient and/or the patient’s non medical; e.g. vision plan; insurer.”

Hopefully, billing decisions for doctors and staff and payment decisions for insurers will be simpler and more consistent if all can develop and adhere to firm policy when making billing and payment decisions. Optometrists are very good at providing excellent, cost effective and high quality health care services. It’s time to get better at making consistent decisions relative to choices of procedure and diagnosis codes and claims submission.

Related ROB Articles

How to Coordinate Medical and Vision Plan Billing

Outsource HR and Billing to Improve Practice Quality and Efficiency

Use EHR to Optimize Billing and Coding Process

Charles B. Brownlow, OD, is an eyecare consultant and AOAExcel Medical Records and Coding Consultant. To contact him:

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