Ophthalmology and Optometry Coding Alert

Use the 99200 codes for patients with specific problems -- but make sure your documentation backs them upOphthalmology coders can use their own set of codes for ophthalmic evaluations instead of the evaluation and management codes, but the challenge is knowing when to use which set of codes.Both sets of codes -- the E/M codes (99201-99215, Office or other outpatient visit ...) and, in the Medicine section of CPT, the general ophthalmological services codes (92002-92014, Ophthalmological services; medical examination and evaluation ...) -- describe office visits.There is no set rule regarding when to use the E/M codes or the Medicine section codes, says Jeffrey Restuccio, CPC, CPC-H, principal of Ritecode.com, who led the "Coding and Reimbursement for Ophthalmological Procedures" seminar at the Coding Institute's 2008 Ophthalmology Coding & Reimbursement Conference. So how do you decide which to report?Switch to E/M Codes for Complicated ExamsExperts warn: Don't choose based on amount of reimbursement. 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, report an eye code. If, however, he is evaluating the eye as related to a systemic disease process, report the appropriate E/M code.Example 1: A new patient presents complaining of blurred vision. The ophthalmologist performs a comprehensive examination, including checking her visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure. Since this is an examination of the eyes' function, use 92004.Example 2: A patient with chronic blepharitis comes in due to a recent foreign-body sensation. During the case history, the patient mentions a recurring headache. The patient had an unremarkable comprehensive exam four months ago, and you don't think it's necessary to do another dilated exam. A slit lamp exam reveals a lash rubbing the cornea on the painful eye. Refraction indicates a significant increase in hyperopia, which may explain the headache.You can report an E/M code -- as long as you meet the higher standard of documentation for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined in the E/M codes that are not specified in the eye codes. Many carriers look for an E/M code if there is a medical diagnosis.Check Carriers for 'Comprehensive' DefinitionYour CPT manual has definitions of "intermediate ophthalmological services" and "comprehensive ophthalmological services" Be careful, however: Individual carriers have refined those definitions even further.If you don't meet your carrier's definition of "intermediate" or "comprehensive" eye exams, you should report an E/M service code instead of an eye code. CPT defines an intermediate ophthalmological service (92002 for a new patient, 92012 for [...]