Submitting Patient Conditions Requirement
As a health-focused vision care company, VSP places an emphasis on early detection of chronic conditions through an eye exam. Your medical findings are then integrated in a HIPAA-compliant manner with the healthcare system to provide holistic care to patients.
Doctors are required to submit patient conditions through eClaim on eyefinity.com, practice management software or paper claims. Patient condition submission is monitored as part of the Quality Assurance (QA) Program and results are provided in the QA Review Summary. Outcomes identifying the need for improvement will require the doctor’s acknowledgement of the results and an improvement action plan.
The Value of Submitting Patient Conditions
When you submit patient conditions, VSP can demonstrate to clients, health plans, and disease management companies the full scope of services you provide and reinforce the role of vision care as a key component of overall health care. We see the value resonate in the form of new and renewed contracts, which bring more VSP members to your practice. VSP also helps health plans increase their HEDIS and Star quality ratings by reporting annual eye exams received by patients with diabetes. Additionally, VSP uses this information to direct patients with diabetes and prediabetes back to your office if they have not received an eye exam in 14 months.
Note:
More information on HEDIS and Star quality ratings can be found on VSPOnline. Under Administration select Submitting Patient Conditions and then click on the HEDIS and Star Ratings tab.
Benefits to Your Practice
- Promotes and quantifies optometry’s participation in medical care.
- Helps facilitate medical care for your patients.
- Brings patients into your office and helps keep them there.
- Provides opportunity for your practice to earn additional revenue.
Reimbursement Opportunity
VSP offers additional reimbursement* when you include diagnosis codes for patients with chronic conditions. For each patient identified, you can earn:
- $5 for reporting diabetes and/or diabetic retinopathy.**
- $2 for reporting hypertension and/or high cholesterol.
Note:
Payment won’t exceed $5 and isn’t cumulative. If a $5 condition and a $2 condition are checked, then $5 is paid. If two $2 conditions are checked, $2 is paid. The patient’s medical record must indicate any condition submitted on a claim.
*Additional reimbursement only applies to VSP Signature Plan® and VSP Choice Plan® claims billed with one of the following exam codes: 92002, 92004, 92012, 92014, S0620 or S0621 and one or more patient condition.
**VSP WellVision Exam® claims with a date of service of January 1, 2024, and later must include the following to earn the $5 patient condition payment.
- Indicate the patient has diabetes or diabetic retinopathy via the patient condition checkbox in eClaim on eyefinity.com or include the appropriate diagnosis code, and
- Include the appropriate diabetic eye exam CPT Category II code.
Indicating Patient Conditions on Claims
When submitting a claim, check the appropriate box(es) on eClaim and/or enter diagnosis codes for the patient’s conditions. This includes diabetes, diabetic retinopathy, hypertension high cholesterol, and patients at risk of prediabetes. Additional conditions like glaucoma and age-related macular degeneration can be noted using diagnosis codes.
Refer to the following section for more information on submitting patient conditions including the eClaim process and applicable diagnosis codes.
- Eligibility and Authorization
Patient Education
Patient education resources are available to you on VSPOnline. Under Administration select Submitting Patient Conditions and then click on the Resources tab. Use this information to educate your patients and demonstrate that your role in their care may include more than an annual eye exam.
VSP Payment Guidelines for Coordination of Benefits (COB) Claims between a Medical Health Plan or Medicare and VSP Plans
The patient’s chief complaint or presenting symptoms determines the primary diagnosis on the claim. If the primary diagnosis is a medical eye condition, and you participate on the patient’s medical insurance panel, you may bill their medical insurance as primary and coordinate benefits with VSP as secondary. Some major medical plans cover routine annual eye exams, or an exam for patients with conditions such as diabetes, regardless of whether they present with medical symptoms. If the medical plan is going to be billed, it is extremely important to explain this to the patient.
If the patient has no medical chief complaint and the medical plan does not cover routine/annual eye exams, bill VSP.
Note:
Proper documentation of the patient’s chief complaint, medical condition(s), related eye symptoms, and high-risk medications should all be recorded in the presenting reasons for the patient’s visit
For further details, refer to VSP’s COB guidelines.