Ophthalmology and Optometry Coding Alert

Insurance companies often dont recognize the difference between a vision exam and a medical exam if the coder uses the eye codes (92002-92014). HMOs and PPOs tend to regard the evaluation and management (E/M) services codes (99201-99205, 99212-99215) as being for medical exams, and the eye codes for vision exams. This is an incorrect assumption on their part, but that doesnt solve the problem for the coder which may include rejected claims.

Medicare (which has no vision coverage) can differentiate between types of service by diagnosis code, but other payers claims systems are not as sophisticated, explains Raequell Duran, president of Practice Solutions, a coding and compliance consulting company specializing in ophthalmology and based in Santa Barbara, Calif. Duran recommends creating a matrix or a chart organized by payer that indicates how they want these claims to be coded (For a sample chart go to our Web site at www.medville.com/extra/opc). This chart can be kept at the check-out desk or in the exam lanes. For example, in one column you can list the payers. In the next you can list how the respective payer wants a medical exam to be coded (e.g., 99xxx or 92xxx).

And in the third column, you can list how that payer wants a vision exam to be coded (e.g., 92xxx). This will make it easier for staff to code appropriately before the claim is even filed and cut back on the extra work of refiling a claim. If you have an insurance company that has their claim system set up to recognize the eye codes as vision examinations and the evaluation and management codes as medical examinations, you will need to adjust how you are submitting your claims to them, says Duran.