Clearly See the Answers to These Pediatric Vision Screening Medical Billing FAQs
Discover key FAQs about vision screenings medical billing with well-child visits, including code differences, billing practices, denial appeals, and modifier usage.
Pediatric Billing & Coding Alert
Guideline On Billing Vision Screenings With Well-Child Visits
Vision screenings often raise questions regarding coding. Many pediatric coders struggle to determine which codes to apply and when to use them. To assist you, we’ve gathered four of the most frequently asked questions (FAQs) related to this topic.
This resource is for you if you’re seeking a clearer understanding of vision screening coding.
Question 1: How do the visual screening billing codes 99172, 99173, and 99174/99177 differ from one another?
Answer: CPT code 99172 (Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision through pseudoisochromatic plates, and field of vision, which may also include some evaluations for contrast sensitivity and vision under glare) is designated for vision screenings in occupational medicine for adults in jobs that require exceptional eyesight or comply with vision safety regulations. Consequently, it is not typically used in pediatric contexts.
CPT® code 99173 (Screening test of visual acuity, quantitative, bilateral) is commonly utilized for pediatric vision screenings. According to the CPT® guidelines for this code, providers typically conduct the screening using a Snellen chart, which is the well-known eye chart displaying letters in rows that decrease in size.
CPT® codes 99174 (Instrument-based ocular screening, such as photo screening or automated refraction, bilateral; with remote analysis and report) and 99177 (with on-site analysis) are also applicable in pediatric settings, particularly for preverbal, nonverbal, or non-cooperative patients. This service uses a device to capture images of the child's eye to screen for any abnormal conditions. Code 99174 is reported when your office sends the images to an external interpreter, while 99177 is used when the interpretation is done in-house. Jan Blanchard, CPC, CPEDC, CPMA of Vermont-based Physician’s Computer Company, notes, “Workflow and vendor variations can influence which of these codes is applicable for the services your practice provides. Ensure you confirm with your vendor how to determine the interpretation location for each instance of these tests.
Additionally, it's important to note that the 2024 RVU value for 99173 is less than 64% of that for 99177.”
Question 2: Can I separately bill a vision screening with a physical?
Yes, in certain situations. According to CPT® guidelines for the screening test, “other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive medicine services).” This includes annual well-visit services reported with codes 99381-99384 (Initial comprehensive preventive medicine evaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures for new patients) and 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual for established patients). Many services associated with a preventive evaluation and management (E/M) service can be billed separately.
Additionally, you can bill for vision screenings like 99173 alongside developmental screenings such as 96110 (Developmental screening, including a developmental milestone survey or speech and language delay screen, with scoring and documentation using a standardized instrument) and behavioral screenings like 96127 (Brief emotional/behavioral assessment, including depression inventory or ADHD scale, with scoring and documentation using a standardized instrument), depending on the patient’s age and developmental stage.
In fact, according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, “all screening and testing services can be billed with any E/M service, whether it’s a preventive or sick visit E/M, under appropriate circumstances.”
Additionally, suppose the patient receives a vaccine during the service. In that case, you can also bill for the vaccine and its administration using codes 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified healthcare professional).
Question 3: What steps should I take if I submit the vision screening and physical separately, but the payer denies the claim?
As previously mentioned, CPT® guidelines permit billing these services separately. However, some payers may still consider the services bundled and deny the claim. This highlights the importance of thoroughly understanding your payer contract.
If you receive a denial of this nature, the best course of action is to review the contract for any agreements that might override CPT® guidelines. If there is no language regarding bundling, you can appeal the denial. CPT® clearly states that screenings are distinct services, so if payers are bundling them without prior arrangement, they violate your contract.
Remember: To improve the chances of a successful appeal, use clear and concise language and include any relevant documentation. However, if the payer has explicitly stated that the services are bundled in the contract, note that to prevent similar denials in the future.
Question 4: Can I apply modifiers 52 or 53 to report a vision screening that the pediatrician cannot complete because the child cannot recognize certain letters or remain long enough?
Unfortunately, using modifier 52 (Reduced services) or 53 (Discontinued procedure) with 99173 or 92551 (Screening test, pure tone, air only) would be incorrect in this situation.
According to Appendix A of the CPT® manual, modifier 52 applies when “a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional.” In this case, the service wasn’t terminated by the pediatrician's choice; rather, the patient's circumstances made it impossible to complete it.
Also, modifier 53 is inappropriate here, as it is intended to “terminate a surgical or diagnostic procedure,” and neither 99173 nor 92551 meets that definition.
Given these conditions, your only viable option would be not to bill for the service.
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BillingFreedom stands out as the premier Pediatric Medical Billing Service provider, expertly navigating the complexities of pediatric billing. With a deep understanding of CPT® guidelines and payer contracts, our team ensures accurate coding for vision screenings, well visits, and developmental assessments. We handle challenges with precision and clarity, such as service denials and bundling issues. Our commitment to maintaining compliance and optimizing revenue allows healthcare providers to focus on patient care while we manage billing intricacies.
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