With the release of new FDA approved eye drops to improve near vision, questions are pouring in on the legal ways to get paid for this service.  The AOA sent out a correct but complex explanation and as usual, the blogs are already full of “ideas”.  We can make this very simple.

Presbyopia is a vision condition, NOT A MEDICAL CONDITION.  Prescribing these drops is not medically necessary with respect to insurance rules.  There are two ways to consider handling the prescribing of these drops.

  1. The drops are a proposed vision-correcting alternative.  You can prescribe them as part of your routine wellness examination and bill the patient or the patient’s vision plan – just like glasses.  No extra reimbursement but an option.
  2. Feel you should be reimbursed for additional care related to this option?  This is a non-covered service at every turn and there is only one real way to get reimbursed for the additional care – bill the patient directly.  You can do this using an office visit code.  As this is NOT medical care and the ophthalmologic codes are already used for non-medical services, an intermediate ophthalmologic code would be a good consideration. You can also consider simply making up a service code and assigning whatever fee you want.  In either case, it is recommended you perform a separately documented service on the same day as their routine visit or even better, have the patient return for a separate visit to discuss, potentially trial, and if appropriate prescribe the medication along with discussions regarding expectations and potential side effects.

And despite creative attempts presented on the blogs already, these are things that you should NOT do:

  1. Use option #2 above, have the patient sign an ABN, and attempt to bill the patient’s insurance.  It will be denied – you are simply sacrificing trees in the rainforest. Get your money upfront.
  2. Bill a medical visit with a diagnosis of eye pain, blurred vision, subjective vision loss/disturbance, headache, or other creative attempts to circumvent correct billing.  This is blatantly fraudulent.
  3. Bill a high-level E/M code (99214) because you are “prescribing medication”.  Presbyopia is not a medical condition and not a complex problem with an unknown prognosis.
  4. Bill medical under an “unlisted procedure” code (92499) or “not medically necessary service” (S9986).  These will be denied if submitted to medical payers and even if they slip through will be denied on audit.

You should get paid for what you do – but do it the right way.