Medical Plan vs. Vision Plan

What’s the difference?

The monitoring of eye and eyelid related conditions that cause you discomfort or potentially cause damage to your eye(s) or vision are health conditions that are covered by the same insurance plan that you would use for discomfort or potential damage to any other part of your body. That is, your “major medical insurance” plan is responsible for any visit to our office when the “reason” or purpose is to evaluate a known “condition” or “symptom” and manage it appropriately.

In some cases these conditions are temporary and, once resolved no longer need management (a cut, an abrasion, a “broken blood vessel,” etc). Most of the time, they are ongoing or “chronic” and require persistent evaluation and management (dry eye, eyelid conditions, cataracts, glaucoma “suspects,” etc). Therefore, if you have one of these conditions, it is the appropriate and responsible approach for us to use your “medical” insurance for the care provided when an office visit has that “focus” or “reason.” Medical visits are given “codes” under specific guidelines known as the “CPT code” and we will due diligence to follow acceptable, ethical and proper coding practice at each visit.

When an evaluation of the “refractive power” of your eyes is necessary and performed (along with muscle-focussing evaluation and binocular vision evaluation when necessary), this is coded in CPT as a 92015, is not billable to medical insurance, and is the responsibility of the patient. Also, every patient is screened with high resolution retinal imaging, and the fee for this service is the patient’s responsibility as well.

Patients who have a “Vision Benefit Plan” and are eligible for an evaluation/examination at the time of their visit may specify that we utilize that coverage as appropriate.  In that instance, the “refraction-92015” is usually a covered service of the vision benefit plan.

Please feel free to contact us with any questions.

 

– The Team at Fig Garden Optometry