Ophthalmology and Optometry Coding Alert

Last years CPT revised the guidelines for intermediate ophthalmological services (92002, 92012) to differentiate between routine ophthalmoscopy and extended ophthalmoscopy. The language was also changed to clarify that the service of refraction and prescription of lenses is not included in the eye codes, and is separately billable with 92015. What, then, is included in 92002 and 92012, and what is included in comprehensive ophthalmological services (92004, 92014)?

It depends on your carrier, says Raequell Duran, president of Santa Barbara, CAbased Practice Solutions, which specializes in ophthalmology consulting in billing and collections. Currently, there is not a national policy for the documentation requirements for the eye codes, says Duran. When a national policy does not exist the local carrier has the authority to create its own policy.

Even whether or not dilation is required in order to bill a comprehensive eye exam is up to the carrier. In some states, a dilated examination is required to bill a comprehensive exam, says Duran.

Its very important that you contact your carriers provider relations department to find out what their requirements are, explains Duran. You will see below how widely policies can differ in terms of these codes.

Intermediate ophthalmological services are for evaluation of a new or existing condition complicated with a new diagnostic or management problem, according to CPT. The new condition doesnt necessarily have to relate to the primary diagnosis. Intermediate services include history, medical observation, external ocular and adnexa examination, and other diagnostic procedures as indicated.

The language new or existing condition complicated with a new diagnostic or management problem has been incorporated by some Medicare carriers as a requirement for intermediate ophthalmological services. In those states, if you cant satisfy this requirement, you need to use the E/M codes to bill the service , explains Duran.

In Texas, the Medicare carrier recognizes specific examination elements. To bill for a comprehensive exam (92004 or 92014), you must perform nine or more of the specified elements, including a dilated fundus examination. To bill for an intermediate exam (92002 or 92012), you need to perform eight or fewer of the specified elements.
The 11 elements on the Texas Medicare carriers list for the eye codes are:

Visual acuity
Basic visual fields

Eyelids and adnexa

Ocular motility

Pupils and iris
Cornea

Anterior chamber
Lens

Intraocular pressure

Optic disk

Retina (including vitreous, macular, periphery, and vessels)

CPT does give some guidance on how to differentiate between intermediate and comprehensive ophthalmological services codes, but you must go to your Medicare carrier for a definitive distinction. That said, there are two examples in CPT of scenarios for intermediate ophthalmological services. In the first, the patient has an acute complicated condition, such as iritis, which requires a review of history, an external examination, ophthalmoscopy, and biomicroscopy. In the second, the patient is established and has a known cataract and requires a review of interval history, an external examination, ophthalmoscopy, biomicroscopy, and tonometry.

As for the comprehensive ophthalmological services (92004, 92014), CPT says these codes are for a general evaluation of the complete visual system. You do not need to perform all of the components at one session. Included in the comprehensive codes are history, medical observation, external and ophthalmoscopic examinations, gross visual fields, and basic sensorimotor exam. In addition, CPT states, the comprehensive codes often include biomicroscopy, examination with mydriasis or cycloplegia, and tonometry.

Finally, unlike the intermediate services codes, CPT says that comprehensive services always include the initiation of a diagnostic and treatment program. The definition of initiation of a diagnostic and treatment program includes prescription of medication, and arranging for laboratory procedures, radiological services, consultations, and diagnostic or treatment services.

The example in CPT of a scenario requiring a 92004 or 92014 is a patient with symptoms indicating possible disease of the visual system, such as glaucoma, cataract, or retinal disease, or to rule out disease of the visual system.
In neither the intermediate nor the comprehensive codes should you try to separately bill for the service components such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry, or motor evaluation. These are included in both.

Not all carriers make the distinction between intermediate and comprehensive ophthalmological services clear. For example, Transamerica, a Medicare carrier in California, refers to something it calls complete eye exams. According to Transamericas policy, complete eye exams are for the initial eye exam or a follow-up eye exam done for diagnosis and/or treatment, and must include the following elements.

Visual acuity determination (with a potential acuity meter)

Tonometry

Gross visual fields

Muscle balance

Slit lamp examination/microscopy

Transamerica doesnt specify any distinct number of elements to differentiate between intermediate and comprehensive levels, says Duran. In this kind of situation, you must rely on how the carrier defines the type of service. In addition to the differences between documentation requirements, carriers also have frequency guidelines in place for the established comprehensive visit code: 92014. Most commonly, Medicare carriers will allow and pay for one 92014 service in a six-month period, Duran explains. There is at least one Medicare carrier that only allows one 92014 per year, she says. But that should not prevent you from billing the service, she adds. If the service is documented correctly and it was medically necessary, the carrier is responsible for payment. Unfortunately, Duran notes, if the claim is initially denied due to a frequency guideline, it will have to be sent through the first level of appeal which is a request for a review of the original claim determination. Sometimes these will even require the second level of appeal which is to request a fair hearing. Whether requesting a review or a fair hearing, be sure to include with the request all pertinent documentation proving the medical necessity of the service.

Special Ophthalmological Services

Special ophthalmological services are those in which a special evaluation of part of the visual system is done. The definition of special is services which go beyond the services included under general ophthalmological services. Special services may be reported in addition to general services or E/M services.

Examples of special services are fluorescein angioscopy, quantitative visual field examination, refraction and extended color vision examination. Where indicated by the CPT description for one of these codes, interpretation and report are an integral part of special ophthalmological services. Technical procedureswhether performed by the physician or notare part of the service, but not the service itself.

Ophthalmoscopy tip: Here is the insurance worlds view of routine ophthalmoscopy: it is an ophthalmoscopy performed in the absence of signs, symptoms, or known diagnostic conditions that would medically warrant an ophthalmoscopy. Routine ophthalmoscopy is part of general services, both intermediate and comprehensive. Extended ophthalmoscopy has its own codes: 92225 for the initial procedure, and 92226 for subsequent procedures. If an extended ophthalmoscopy is warranted under medical necessity, then you would be able to use those codes.

Code 92225 is for the initial extended ophthalmoscopy with retinal drawing (for example, for retinal detachment or melanoma), with an interpretation and report. 92226 is for subsequent extended ophthalmoscopy. Again, when billing Medicare it is vital to know whether your carrier has a medical policy for these two codes. Several carriers have specific drawing requirements which are not all the same from carrier to carrier. In addition, most have developed diagnostic code listings that validate these services. If you submit a diagnostic code not on their list, the service is denied and you have to fight through the appeals process based on your contention of medical necessity.