Does Medicare Pay for Your Routine Eye Exans?

[JohnR464906]

I have gone to several different optometrists during the past several years for what I believe are routine eye exams and got new eyeglasses when my prescription changed.

I believe those exams were pretty much the same at each place, and included “refraction” to determine my eye glasses prescription, plus they checked my eyes for glaucoma and cataracts, and looked at my optic nerve - none of which I’ve never had any issues, luckily.   These exams each took about 30 minutes each optometrist.

Two of these optometrists charged me about $125.00 for the exam, which I paid.  The 3rd optometrist charged $253.00 for the exam, asked me to pay them $45.00 for the refraction portion of that charge (which Medicare does not cover), which I did pay them, and then they billed Medicare for the remaining $208.00 (which Medicare subsequently paid to them).

I have looked at the Medicare website, all of the invoicing codes and descriptions for this optometrist’s billing to Medicare,  I don’t have any pre existing conditions, like diabetes for example that might qualify for Medicare coverage, and I cannot see where any of my other medical history, or the eye exam that I got at that optometrist, justifies Medicare paying them.

My question is:  Does Medicare pay your optometrist for most of the cost of your “routine” eye exams?

[GailL1]

@JohnR464906 

You have hit upon one of the [Traditional] Medicare loopholes in coverage and there are others.

A few things you do have to remember

1.  A provider, in this case, an opthalmologist or an optometrist, has to agree to accept assignment or be a non-participating provider that will bill Medicare and you pay a 15% up charge for the service to be covered at all.

2.  Refractory exam or test is never covered under Medicare - this is for the RX for glasses or contacts.  Although if you have OHI, it may cover this part or some of it - like Medicaid or CHAMPVA or TRI-care for life.

3.  The other test like for glaucoma  or macular degeneration (AMD) should only be covered IF there is either a history of such a condition in your family or diabetes.  But coding is everything and thus if coded this way indicating a familiar linkage, or a age linkage, then Medicare will cover the test at the regular rate of 80% of the Medicare negotiated rate - with you as the beneficiary picking up the other 20% or it is picked up FOR you by a Medigap plan or OHI.  These are covered under Part B.

4.  However, for both of these conditions, a test has to be performed to ascertain if the condition is apparent or suspected - thus it is medically necessary to see if the test indicates the condition - thus there is coverage for all beneficiaries.

4.  There is no preventive test that is shown for these test that is rated “A” or “B” by the USPSTF where these would be covered at 100% of the cost. They are only covered by Medicare at the standard Part B rate of 80% of the Medicare negotiated rate.  Your OHI or a Medigap plan will pick up the remained or some of it depending on the other plan of coverage.

For Glaucoma screening:

Medicare Part B (Medical Insurance)

covers this screening once every 12 months if you’re at high risk for developing glaucoma. 

You’re considered high risk if at least one of these conditions applies to you:

• You have diabetes.
• You have a family history of glaucoma.
• You’re African American and 50 or older.
• You’re Hispanic and 65 or older.

For Macular Degeneration screening:

Medicare Part B (Medical Insurance)

may cover certain diagnostic tests and treatment (including treatment with certain injectable drugs)  if you have age-related macular degeneration (AMD).

Medicare really should rewrite some of their coverage details.  I feel that it is a good idea for everybody to have these test annually after a certain age - whether there is familiar or ethnic linkage or not because early diagnosis and early treatment could make all the difference.  Pending that the beneficiary wants the test.  

[JohnR464906]

Thank you for a very comprehensive reply.  After carefully reading everything that you’ve said, re-reading it several times, and then comparing what you’ve said to my own situation, other than getting older year after year (in which case all of us can suspect that sooner or later something is bound to get us) I still see no justification whereby this specific optometrist can honestly justify billing Medicare for my eye exams, nor do I see Medicare’s justification for their payment.

p.s.  please note where I said “I see…”.  It could be “I see wrong”.😃

[GailL1]

@JohnR464906 

I agree that these tests are being covered for beneficiaries who are not high-risk.  There are others as well that I have questioned in the past for this same type reasoning.

The question is still IF the test need to be done every year, less often or even at all for those of us who have no high risk classification.  That’s a job for the medical society - but then they need to be all onboard and the coding for these test needs to be customized for those that are at risk and those that are not at risk.

I am ONLY going to cover the glaucoma test here in my analysis but the same could be done for the macular degeneration testing.

CMS.gov - Medicare Coverage Determination for Glaucoma Screening 

This seems to have been revised just last November (11/2024)

Note that it says that the beneficiaries medical records should indicate their high risk category by the requirements and it gives the diagnosis codes and both have the high risk definition.

You can make a statement or ask a question at the end of the article but from experience you may or may not get any reply.  The U.S. Preventive Service Task Force is the pseudo-government agency in charge of doing the research on preventive testing and grade them - anything that has an “A” or”B” rating was used by the PPACA law to get these services with no out of pocket cost.  

USPSTF - Glaucoma Screening - “I” Rating

See the “Recommendation of Others” to show how this is somewhat controversial in when and how testing occurs for those who are NOT in the classification of high risk.

I could give you evidence of other type of procedures that are similar - medical necessity is sometimes a tricky area but the documentation of the high risk condition(s) is pretty much set in stone here but yes, many opthalmologist and optometrist get paid for this test even if the beneficiary believes they have no risk factor because it is all in the coding - who actually checks the documentation?

What code did the optometrist use in your case?  You could ask him or her what risk group you fall into and if this is in your chart and how did he/she come to this conclusion.  Most likely the code used is used for all beneficiaries - indicating they are all at some sort of risk.

This is the written guidance that are given to the providers from CMS.

CMS.gov - Medicare Learning Network - Education and Outreach - Medicare Vision Services 

 It does seem that all of these Medicare documents say the same thing - agreed?

Is Medicare paying for something that should not be covered?  Be sure to duck when it hits the fan.

EDITED TO ADD:

Seems the Diabetes Screening coverage has a lot of us in the descriptive profile of being hit by this disease - at risk.

So I am wondering if this rather board description puts many of us in this at risk category?

Medicare.gov - Diabetes Screening  

[JohnR464906]

Thank you once again for your very comprehensive reply.

Before I respond farther, I would like to correct one of my earlier comments that Medicare paid all of this optometrist’s charges (except for the refraction charge which I paid and was not billed to Medicare).  Looking online at my Medicare claim from this optometrist I see that it showed where I might be billed for 20% of the claimed amount.  I don’t have any supplemental insurance coverage for these eye exams, and I do not recall subsequently  being billed (nor can I find any record of paying) for it.

In any case, related to the glaucoma screening portion of my exam, I do not have any of the specified conditions that would place me in a high risk category.  And during my visit at the optometrist, the ophthalmic technician conducted an air pressure test and a slit lamp opthalmoscopy.  I believe they would have dilated my eyes in lieu of the opthalmoscopy, but when I said had I known in advance of the dilation I would have had my wife there to drive me home they did the opthalmoscopy instead.  

(I hope I have the correct terminology for these procedures…had  I not looked these up online I might have described them as sitting on a chair and looking into a machine that flashed a bright light in each of my eyes.😃)

The invoice coding and description of my visit is as follows:

Code 92250 - Fundus photography…diagnosis H40.013

Code 99214 - …Established patient. Level 4. Diagnoses H40.013, H43.813, H50.52, H25.13

As I mentioned previously, I believe my total visit time at the optometrist lasted about 30 minutes, and possibly less.  Perhaps 10 of the 30 minutes was spent with the optometrist, and the remainder was with the receptionist and the technician.  It’s possible that I have forgotten, but I do not recall a discussion or mention of glaucoma with anyone during my visit.

[CBtoo]

I was told if I used my annual eye wellness exam (for a lack of a better word - original medicare) on a visit and then paid an additional fee (in my case $50) then they'd do the refraction exam I needed to update my glasses (actually I think they do most of it anyway in examining one's eyes) so it would more be giving me the Rx for glasses..