Ophthalmology and Optometry Coding Alert

Three of the five most-commonly reported codes are different from ophthalmologists’.

If your optometry practice is eager to get a look at the most commonly-reported codes, we’ve got those as well, also courtesy of Frank Cohen, MPA, MBB, of healthcare consulting firm DoctorsManagement. Check out the following list of commonly-reported codes by optometry practices (not including codes that strictly describe PQRS), along with tips on how to maximize billing for these services.

#1 Most Frequently Billed Optometry Code: 92014

This eye exam care code represents 16.83 percent of optometrists’ claims, making it the number one most frequently-reported code in this specialty. See our article, “Bill the 5 Most-Frequently Billed Eye Care Codes With Ease” for tips on how to report this code, since it was also the top-reported code by ophthalmologists.

#2 Most Frequently Billed Optometry Code: 92015

Optometrists reported the determination of refractive state code on 13.42 percent of claims.

Tip: Because neither the ophthalmological services codes nor the E/M codes include refraction, some practices charge for refraction using 92015, but many insurers consider refraction non-payable, unless they have a separate vision plan that will pay for it. If you verify the patient’s insurance and find that refraction isn’t covered, you should issue the patient an advance beneficiary notice (ABN) before you perform the service so the patient knows she is responsible for the charge.

#3 Most Frequently Billed Optometry Code: 99213

Optometrists reported the level three outpatient office visit code on 6.75 percent of claims. This code requires two of the following three criteria: an expanded problem-focused history, an expanded problem-focused exam, and/or medical decision-making of low complexity.

Tip: To meet the expanded problem-focused history requirement, you’ll need at least a brief history of present illness (HPI). When documenting a brief HPI, “the medical record should describe one to three elements of the present illness,” Part B MAC CGS Medicare says in its 99213 guidelines.

Those one to three elements can be selected from the following list: Location, severity, context, modifying factors, quality, timing, and associated signs/symptoms, CGS indicates. You must also document at least one element from the ROS to obtain an overall result of extended problem-focused history for a level 99213.

If you don’t have this level of HPI and ROS, your history won’t justify reporting 99213, but all is not lost. Without the HPI, the history will not need to be considered in the count toward the 99213 tally. Because 99213 only requires you to meet two of the three elements, you can still report the code if your exam is at least expanded problem-focused and your MDM is of at least low complexity

#4 Most Frequently Billed Optometry Code: 92250

The fundus photography code was reported on 6.23 percent of optometrists’ claims.

Tip: Most insurers will not reimburse you for fundus photography if you perform it on a healthy patient, since this service typically applies to patients with retinopathy.

“Fundus photography will be covered if accompanied by fluorescein dye angiography when used to evaluate abnormalities or degeneration of the macula, the peripheral retina or the posterior pole,” says Part B MAC First Coast Service Options in its policy for this code. “Fundus photography may be covered as a stand-alone procedure, without fluorescein dye angiography, following recently performed nonsurgical or surgical treatment for macular pathology.”

#5 Most Frequently Billed Optometry Code: 92012

This eye exam care code represents 5.80 percent of optometrists’ claims, making it the number five most frequently-reported code in this specialty. See our article, “Bill the 5 Most-Frequently Billed Eye Care Codes With Ease” for tips on how to report this code, since it was the second-most frequently-reported code by ophthalmologists.