EM Coding Alert

Question: I just started at an ophthalmology practice and am having trouble figuring out when to report an E/M code rather than eye exam/evaluation code. Can you explain the difference and when to use each one? For example, what would I report when a new patient presents complaining difficulty reading traffic signs? The ophthalmologist performs a comprehensive examination, including checking her visual acuity, gross visual fields, ocular mobility, retinas, and intraocular pressure.

Pennsylvania Subscriber

Answer: The general rule for CPT^® codes is to pick the code that most clearly describes the service the ophthalmologist renders. If he is strictly evaluating the function of the eye or doing a “routine” eye exam, report an eye code from the 92002-92014 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program…) range.

If, however, the ophthalmologist is evaluating a more far-reaching systemic disease process, report the appropriate E/M code.

“The American Academy of Ophthalmology (AAO) has stated in the past that the E/M codes should be used for patients presenting with chronic conditions, new problems, injuries, etc.” notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “The eye codes are advised to be used for routine vision exams for prescriptive eyewear/contact lenses. But the AAO also stated that the choice is made by the physician, as either codes may be used for billing.”

Watch for: Some payers will not pay for general routine vision exams unless covered under the insured’s policy and only the eye codes can be submitted once annually, Mac warns. 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.

Caution: The difference in code could also mean a difference in which payer to bill. Some patients carry a totally different policy for their routine eye visits versus visits for problems.

Scenario 1: Since the scenario you presented is an examination of the eyes’ function, report CPT^® code 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient 1 or more visits). “The diagnosis will drive whether or not the payer will pay a claim based on policy benefits,” Mac says.