Ophthalmology and Optometry Coding Alert

With 18 plus options to sift through when coding a glaucoma visit, you need these simple guidelines to secure the insurer preferred code that lands payment, not denial. You have four options for coding glaucoma exams, depending on the form and severity of the glaucoma. You are given a choice of using four ophthalmic visit or CPT codes (or "eye codes") (92002-92014, Ophthalmological services: medical examination and evaluation ...), 10 evaluation and management (E/M) codes (99201-99215, Office or other outpatient visit ...), two HCPCS S codes (S0620 and S0621, Routine ophthalmological examination including refraction ...), two G codes (G0117 and G0118, Glaucoma screening for high risk patient ...), or, possibly, a combination of these.

Hidden trap: You cannot use any combination of these on the same day, warns David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. "In coding any patient/physician encounter, your main goal is to bill a code that reflects the type of chief patient complaints or reason for the office visit, and the amount and difficulty of the work done by the doctor," says Gibson.

S0620 and S0621: If a glaucoma patient appears in an ophthalmologist's office for a check up and has no complaints about his eyes (even with the doctor's intensive questioning), then this is a routine exam, no matter what the ophthalmologist finds wrong with the patient. "If the patient had no complaints, no matter how minor, the exam is considered routine," Gibson says.

Report routine exams with the HCPCS S codes (S0620 for a new patient and S0621 for an established patient). A routine exam that uncovers cataracts or pressures in the 40s is still routine if the patient had no complaints, concerns, or previous diagnoses of significant eye problems, Gibson says. However, you should list the diagnoses as secondary on the claim form, says Maggie A. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.

Not all insurance companies recognize S codes, warns Gibson. "You need to know how each payer you work  with wants routine care reported to them, assuming theypay for routine eye care," he says.

"Typically, the S codes are recognized by BC/BS payers," notes Mac. Medicare and Medicaid usually do not recognize them for their beneficiaries.

For Medicare patients, use Medicare's G codes (G0117 for a screening furnished by an optometrist or ophthalmologist, G0118 for a screening furnished under the supervision of an optometrist or ophthalmologist) for patients with no previous history or diagnosis of glaucoma, but due to the patient's age, race, and family history are considered at risk for glaucoma.

"This is not a routine exam but is considered a screening exam, as the patient meets the criteria for early glaucoma screening and is concerned about the health of their eyes without any current symptoms," Mac explains.

V-code benefit: For a screening, report G0117 or G0118 with ICD-9 code V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma). "Code 365.x (Glaucoma) is used as your primary diagnosis if you find glaucoma during the exam; however, a secondary diagnosis from the V code area will be helpful to get by Medicare edits and eliminate the need for a paper claim and report," suggests Alice Marie Reybitz, RN, BA, CPC, CPC-H, a healthcare coding and billing consultant based in Belleair, Fla.

Don't miss: G codes are bundled with E/M and eye codes, Mac advises. "It would be rare for a patient to report to your office for the purpose of a glaucoma screening only.

Therefore, your physician is more likely to perform a complete ophthalmic evaluation which may be coded with the appropriate level of E/M or eye code."