How to Use S-Codes and CPT Codes in the Same Optometry Practice

Jun 15, 2020
7 min read
381 views

We know—billing and coding can be one of the most frustrating aspects of practicing optometry. Here, we're laying out the difference between S-codes and CPT codes, some common mistakes, and what to look out for when billing.

Codes_Featured-Image.png

While CPT codes are most commonly used by optometrists when billing and coding, there is another set of codes whose usage can trip up even the most adept billing veterans. These are S-codes, and this article will cover the difference, when to use S-codes, and clear up some common misconceptions.

What's the difference between S-codes and CPT codes?

S-Codes are:

  • Created by commercial payers like Blue Cross Blue Shield
  • Used by commercial insurances like BCBS and Medicare and Medicaid replacements
  • For covered services and supplies that may not have a CPT code
  • Part of the Health Care Procedural Coding System (HCPCS), Levels 2-3
  • NOT used by Medicare, Medicaid, or other federal health insurance companies

CPT Codes are:

  • Created by the American Medical Association (AMA)
  • Used by all federal and commercial payers
  • For covered medical services and supplies
  • Part of the Health Care Procedural Coding System (HCPCS), Level 1

Will I ever use S-codes?

Only if you want to make money and keep your patients happy. Your insurance contract may require you to perform and bill S-codes.

Some commercial insurances will pay out only if you file a claim with the appropriate S-code. The frustrating part is that whether an insurance requires you to use an S-code depends on the specific insurance, the state, your contract, and the patient’s benefit, and can change status every single year. The two types of carriers notorious for dabbling in S-code benefits are:

  • Medical insurance like BCBS, UHC, Humana, Cigna, Aetna, etc.
  • Medicaid replacement vision vendors like Superior, Envolve, EyeMed, VSP, Davis, etc.

Fun Fact: S-codes include the following commercially covered services: Breast reconstruction (S2068), induced abortion 32 weeks or greater (S2267), using robots (S2900), nicotine patches (S4991), foster care (S5146), anger management class (S9454), and annual gym membership (S9970). Commercial insurers can write a new S-code for anything they want to cover.

Common Mistake #1 – S-Codes are used to charge private pay patients.

Truth: Many medical and vision insurances pay for S-codes. S-codes were NOT created for private pay patients. This is a sticky legal situation. The law says you have to charge equal price for equal services, and if your S0620 routine exam with refraction is basically the same as your 92004/99204 comprehensive exam with 92015 refraction, then they have to be priced the same. However, no one enforces this law (more on this later).

Common Mistake #2 – S-Codes are no longer associated with vision insurance companies.

Truth: Vision insurance companies only cover “routine” examinations with refraction. That service is the S-code S0260. Originally, that is the code that you would bill to them. Over the last 20 years, vision insurance companies decided instead to force you to bill 92004 + 92015 for routine exams, which is technically illegal. The problem is that 92004 describes a higher problem-based medical exam, so it is illegal to bill out if you only did a routine exam. The vision insurance companies are aware of this, but are holding their ground for political reasons. Paying less money for 92004 and calling it routine, they devalue and carve out ophthalmology 92xxx codes. On the other hand, they can advertise to major medical insurance that they can take over contracts for expensive medical eye exams (92004) for a much lower cost, so they win the contract to administer the plan’s “vision” benefits. If optometrists want the upper hand at being fairly compensated for the actual services provided, we need to force the vision insurance companies to only code S0260 for routine exams.

Common Mistake #3 – S-Codes are no longer associated with medical insurance companies.

Truth: Commercial medical insurance will often have an entire carved out benefit for a routine vision exam, which you must bill directly to the medical insurance carrier. If it is an otherwise high-deductible plan, with no separate vision vendor, then your patient will want to take advantage of the routine coverage. But it must be billed out exactly the way the insurance company specifies, or else it will simply be applied to the deductible and pay nothing. Example filing requirements:

  • The exam must be an S-code, like S0620 or S0621
  • The exam must be a 92-code, like 92004 or 92014
    • Refraction must/must not also be coded
  • The diagnosis must be refractive, like H52.13 (myopia)
  • The diagnosis must be a Z-code, like Z01.00 (eye exam, no abnormal findings)

Common Mistake #4 – S-Codes do not need to be used if I don’t want to.

Truth: If a patient’s chief complaint is “I feel and see perfectly, and I want a routine eye exam,” and your exam reveals a pair of pristine, godlike, perfect emmetrope eyes, then you can only bill out S0260, and you can only diagnose Z01.00 (eye and vision exam without abnormal findings).

The habit you are in of billing out 92004 for a routine vision exam is still illegal; vision insurance companies forced us all into the bad habit of falsely upcoding routine exams from S0260 to 92004.

However, if you look hard enough, you should always be able to find a medical diagnosis to validate the higher code. I find all patients have at least 1% of most of the following: meibomian gland dysfunction, environmental dry eye syndrome, allergic conjunctivitis, conjunctivochalasis, dermatochalasis, trichiasis, arcus, anisocoria, peripheral retinal thinning on every myope, glaucoma suspect for any reason (asymmetry, doesn’t follow ISNT rule, larger than 0.50, IOP above 20, family history or demographic risk), vitreous floaters or syneresis, subjective visual disturbance, eye pain, blepharitis, heterophoria, cataracts (unless they have a blow-your-mind newborn baby lens) . . . I could go on. However, as a courtesy, you may choose to bill out S0260 so that your patient gets their benefit.

I have a contract with a local commercial Medicaid replacement who will pay for a contact lens exam on all their patients. But if I bill out 92310 it is denied. They only pay on S0592. I have a contract with another local commercial Medicaid replacement who will pay for a contact lens exam, but only if I bill out 92310.

In some states, some commercial carriers decide to pay for a pair of glasses, but only if you bill out the S-codes (Frame S0516, Lens S0504, Polycarbonate S0580).

Some medical and vision insurances have an allowance towards LASIK. They will require it be billed out either as an S-code (S0800), or else as a CPT code (65760).

Included below is a chart showing S-codes along with their approximately equivalent CPT-codes or V-codes. Find out from each insurance company you contract with how they require you to code for reimbursement each year.

Take home: Commercial insurances use S-codes. If you want to help your patient maximize their coverage, and you want to get paid for all your services, find out every year which local insurances cover and reimburse for specific S-codes.

Service / Material S-Code V-Code / CPT Code
Comprehensive Exam, new patient S0620 99204 / 92004 + 92015
Comprehensive Exam, new patient S0620 99204 / 92004 + 92015
Comprehensive Exam, established patient S0621 99214 / 92014 + 92015
Contact Lens Exam S0592 92310 / 92071 / 92072
Removal of Sutures S0630 65210 / 65222 / 67938
Disposable contact lens S0500 V2520 – V2523
Color contact lens S0514 V2520 – V2523
Scleral contact lens S0515 V2531
Daily wear specialty contact lens S0512 V2599
Single vision ophth lens S0504 V2100 – V2199
Bifocal ophth lens S0506 V2200 – V2299
Trifocal ophth lens S0508 V2300 – V2399
Non-Rx ophth lens S0510 V2100
Polycarbonate Lens S0580 V2784
Non-Standard Lens S0581 V2781
Safety Glasses Frame S0516 V2020
Sunglass Frame S0518 V2020
LASIK S0800 65760
PRK S0810 66999
Phototherapeutic Keratectomy (PTK) S0812 65400
Intraocular Contact Lens Surgery S0596 66985
Genetic Test for Retinoblastoma S3841 81479
covalentcareers
About Bruce Colton, OD

Bruce Colton, O.D. earned his degrees from BYU and UHCO, where he taught Microbiology and did stem cell research with the NIH to help cure macular degeneration. He loves fitting sclerals, prescribing prism, and performing minor surgeries. He has done years of humanitarian work in Argentina, China, and Guatemala. In his free time, Dr. Colton plays with his 3-year-old daughter and newborn son, and takes his wife on romantic dates.


Share
Latest
Jobs
Companies