EM Coding Alert

Question: What criteria should eye care practices use when deciding between E/M codes and ophthalmological services codes?

Arizona Subscriber

Answer: There is no one guideline that dictates when you should use one code set versus the other. Some practices maintain internal guidelines that dictate when they use one code set instead of the other, while other offices make the decision on a case-by-case basis.

You’ll find that certain codes have more stringent guidelines and bullet points that need to be met than others. For example, some practices exclusively use the eye codes for routine eye exams but find the E/M codes more appropriate when evaluating chronic medical conditions. Which you decide to use should be based on the documentation in the medical record.

Also keep in mind that some payers will not pay for general routine vision exams unless covered under the insured’s policy. In some cases, the eye codes can be submitted just once annually. So, for some patients, submitting the eye codes for problem visits more than once per year may pose a problem for payment. Payers may simply have policies in place that direct physicians on which codes may be used — E/M or eye codes — dependent upon the reason for the visit. Remember that the eye code descriptors all contain verbiage describing a medical examination and evaluation with “initiation of” (in the case of new patients) “or initiation/continuation of” (for established patients) a “diagnostic and treatment program.”

Although CPT^® doesn’t specifically explain what it means by “diagnostic and treatment program,” most insurers will list their requirements. For example, Blue Cross Blue Shield of Rhode Island says in its policy, “Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self-limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be reported using 92002-92014. A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014.”

Keep in mind that the BCBS policy is just one example — be sure and ask your payer for its specific requirements.