Billing Information for SAO Members

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Provider Coverage Viewer (PCV)

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Provider Coverage Viewer (PCV)• Use the Provider Coverage Viewer to confirm when a

patient registered with the Ministry of Health had their last eye examination paid by SK Health.

• The PCV provides details on coverage from Supplementary Health, Saskatchewan Income Plan or Family Health Benefits.

• The PCV does not confirm if a patient is diabetic or not.

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Provider Coverage Viewer (PCV)

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Eye Examinations – SK Health2U: ages 0-17 once every 365 days

• Ages 18-64 once every 730 days (2 years) *only for residents with FHB, Supplementary Health

• Ages 65+ once every 365 days *only for residents with Seniors Income Plan21U: tonometry – billable on all FHB, SIP or Supplementary Health patients in conjunction with a 2U

12U: billable for all SIP, FHB and Supplementary Health recipients as well as patients under age 17 for a partial examination – ICD 9 code required

• Except for amblyopia and strabismus a 12U must be beyond 90 days from a 2U, 4U or 22U

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Eye Examinations – SK Health4U: billable for all SIP, FHB and Supplementary Health recipients as well as patients under age 18

• Must be over 90 days from last 2U or 4U• Requires: 0.50D refractive change or 10 degree axis change• Additional conditions eligible for annual examinations:

keratoconus, high myopia (>-8D) *for patients on the aforementioned SK Health programs

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Diabetes• 22U Annual Diabetic Eye Examination

• 31U Tonometry in conjunction with annual diabetic eye examination

• 35U OCT – bilateral professional fee

• 36U OCT – bilateral technical fee

“Not to be used for routine screening of patients and limit of one per year when billed for the management of diabetes”

• Many ODs are billing 35U and 36U at each and every diabetic examination• Doctor’s discretion as to what tests are necessary to provide the highest

level of care to each patient• SAO will attempt to remove this wording from the contract

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Diabetes• 35U/36U do not have to be billed by the same doctor on the same

day as the 22u eye examination. OCT can billed up to 60 days after the exam.

• 37U Photography – bilateral –professional fee

• 38U Photography – bilateral – technical feeProblem: Do we define Optomap images as fundus photos?

Some members are private billing patients for Optomap laser retinal scans for peripheral retinal viewing in addition to billing 37U/38U for fundus photos.

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Diabetes• Visual Fields are not a covered service with a diabetes examination. Members

can bill their usual fee for visual fields if the test is necessary

• Examinations for diabetic patients is NOT covered when it is provided◦ Within the post-operative period following major eye surgery by a physician or optometrist in the

same clinic

◦ At the request of a third party e.g. to complete a report

◦ In respect of the provision of safety glasses for employment purposes

• ODs can NOT balance bill any of the insured services for diabetic examinations

• It is okay to bill diabetic patients for any services not covered e.g. contact lens fees, visual fields, glaucoma work-up, etc.

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Ocular Urgencies & Emergencies15U Initial Assessment• Can be initiated by the patient or upon referral from another doctor for an acute anterior segment disorder

with the following ICD-9 codes:◦ 364: anterior uveitis◦ 370: keratitis◦ 371: symptomatic corneal dystrophies◦ 372: conjunctivitis, subconjunctival hemorrhage◦ 373: inflammatory/infectious disorders of the lids (eg. blepharitis, chalazion, hordeolum, cysts)◦ 374: other diseases of the eyelid◦ 375: inflammatory/infectious disorders of the lacrimal system (eg. Epiphora, canaliculitis, dacryocystitis)◦ 376: preseptal cellulitis◦ 379: episcleritis, scleritis◦ 379: other diseases of the eye (*flashes and floaters)◦ 918, 921, 930: ocular injury, foreign body

◦ The 379 code “other diseases of the eye” was specifically negotiated for patients presenting with the complaint of flashes and floaters. This was noted in a memorandum dated February 28, 2011

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Ocular Urgencies & Emergencies• 16U Follow-Up Assessment

◦ Okay to bill a 16U without a prior 15U. Example: follow-up of a condition such as keratitis diagnosed at routine eye examination should be billed as a 16U on follow-up (without an antecedent 15U)

• 34U Tonometry in conjunction with 15U or 16U when medically necessary *there is no age restriction on 34U’s

• What can we do better?◦ Properly code the disorder being treated. Do NOT mislabel conditions as 372◦ Don’t abuse the codes e.g. billing 16U codes for dry eyes at routine follow-ups for refractive

eye surgery is not permitted. Do NOT bill a 34U unless clinically indicated◦ Do NOT use 379 *other disorders of the eye for conditions other than flashes, floaters (as

well as episcleritis and scleritis)

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Ocular Urgencies & Emergencies• What about post-cataract surgery follow-ups?

◦ The SAO has formally requested coverage for patients for initial post-operative visits

◦ Is it okay to bill 15U after examination post-op cataract patients when referred by a OMD? NO

• Please be careful not to bill a 15U for a foreign body removal when it is a workplace related incident. The patient/patient’s employer can pay the fee for foreign body removal and follow-up or a WCB claim needs to be filed.

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Did you miss the memo?• 40U Visual Field Testing (Screening or Threshold) can be billed

when clinically indicated for SK beneficiaries with:◦ Supplementary Health coverage◦ Family Health Benefit coverage◦ 65+ years of age with Seniors Income Plan

• One service per 12-month period for beneficiaries under 18 or over 64

• One service per 24-month period for beneficiaries 18-64

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First Nations & Inuit Health Branch (FNIHB)• As reported in the May Eye on SAO, FNIHB Treatment Services and Billing will

change effective June 29, 2019. Full details will be shared by representatives from Saskatchewan’s FNIHB Branch at the SAO’s June 8, 2019 AGM

• Details can be found on the members only SAO webpage by navigating to Contracts>NIHB

• Highlights:o There will be a standard allowance (up to +/- 7.00D ametropia) of $275 for optical

products (glasses or contact lenses, coatings, tints, etc.)o There will be a high index allowance (ametropia beyond +/-7.00D) of $415 for optical

productso Eligibility is no longer 12 or 24 months, but rather 1 or 2 calendar years (age dependent)o Eye Exam Rates: TBD

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Veteran Affairs Canada (VAC)• New Benefit Grid for Vision (Eye) Care was released in 2012

without consultation with Optometry. This can be viewed on the members only section of the SAO website

• It is recommended that members bill VAC through Blue Cross and balance bill the patient for the remaining portion of your regular fee schedules

• As seen in the June Eye on SAO, VAC updated the Vision Care Benefit Grid for Low Vision Benefits

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RCMP Update• On August 1, 2015, the Royal Canadian Mounted Police (RCMP)

introduced two new codes: 604220 Lens Benefit, Left Lens (SHC) and 604225 Lens Benefit, Right Lens (SHC)

• These codes are to be used only when the maximum allowance of $700 every two calendar years for codes 604210 Lens Benefit - Left Lens (Corrective) and 604215 Lens Benefit - Right Lens (Corrective) has been reached and one of the conditions below has been met. A calendar year is the period that starts January 1 in a given year and ends December 31 of the same year

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RCMP Update• To exceed the maximum allowance and to use the new codes, the

prescription must show a significant change in the vision of one or both eyes as follows:

1. at least 0.50 diopters on the sphere and/or cylinder; or2. change totaling 0.50 diopters in the add (i.e., 0.25 change in distance and

a 0.25 change in near is a total of 0.50 change in the add); or3. an axis change > 3 degrees of a cylinder power up to -1.00 diopters, 2

degrees for a cylinder power - 1.00 to -2.50 diopter or 1 degree for a cylinder power > -2.50 diopter; or 4) a change in the vertical prism of at least 1 prism diopter or in horizontal prism of at least 2 prism diopters.

• Pre-authorization is required.

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Common Questions• Can we bill SK Health for testing associated with diagnosing,

managing and treating glaucoma? And if so what codes do we use?◦ At this time, we do not have billing codes or the ability to bill Saskatchewan

Health.

• Can we bill a patient when we write a prescription? ◦ Writing a prescription is considered a Standard of Care and you should not

be billing a patient for writing a prescription. It is okay to bill a patient for a duplicate prescription.

• Can we bill a patient for telephone consultations?◦ Yes, members may elect to bill a patient privately for these consultations,

these consultations do not meet the criteria required to bill SK Health.

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Common Questions• Can we bill a patient to write a report?

◦ ODs are within their rights to charge patients for services such as writing reports.

• Can we bill FNIHB for an eye examination for a patient with diabetes?◦ No. FNIHB is the payer of last resort. We must bill SK Health if the patient

has a valid Health Card.

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