Ophthalmology and Optometry Coding Alert

Ophthalmology coders have the luxury of having two sets of codes to represent office visits E/M codes and eye codes that is, if you know when these codes can and can't be used interchangeably.

"While ophthalmologists have the option of utilizing the ophthalmic exam codes (92002-92499) or codes from the Evaluation and Management series (99xxx) for patient exams, our goal is to always choose the code that best describes the service performed," says Linda Abel, CPC, assistant administrator with Hauser-Ross Eye Institute in Sycamore, Ill.

For unique eye codes 92002-92014 to feel like a blessing, you first need to understand what these codes encompass and when they should be reported.

"The basic difference between the two sets of codes is that the eye codes are used for evaluating the function of the eye, whereas the E/M codes are generally used when the physician is evaluating a more systemic disease process," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.

She cites the example of a patient with some symptoms of glaucoma but also with headaches that need to be evaluated in the context of the patient's current condition. This additional evaluation, with the appropriate documentation, constitutes an E/M service.

"But if a patient comes in with just the complaint 'I can't see well,' then the ophthalmologist will simply be evaluating the function of the eye, justifying the use of an eye code," Callaway says.

Sometimes it is hard to tell whether an eye code or an E/M code is appropriate.

For example, suppose a patient comes in for her regular checkup and says, "By the way, I have these other problems or concerns." "This could really go either way and require eye or E/M codes," Callaway says. "Then it is your responsibility to follow the basic CPT rules that advise you to pick the code that most clearly describes the services you are rendering."

The eye codes, like the E/M codes, are divided into new patient (92002 and 92004) and established patient (92012 and 92014) classifications, which are further broken down by their level of service.

Unlike the E/M codes, the eye codes have only two levels of service, intermediate and comprehensive, making it easier to determine the level of service that your ophthalmologist has provided to a patient. Use this chart comparing the components of intermediate and comprehensive eye codes to help delineate between the two.

Differentiation by Documentation

The question still looms: Why would an ophthalmologist or coder opt to use the eye codes instead of the E/M codes, when either set is applicable? For many coders, the answer lies in the depths of documentation.

You tend to need a more extensive history and there are more variations to be considered in medical decision-making when documenting an E/M service rather than an eye service, Callaway says.

While the eye codes don't have national documentation requirements, the majority of local medical review policies provide a list of requirements for the eye codes.

For example, Noridian Iowa's Medicare Part B Policy provides the following 10 physician examination requirements for an ophthalmologic exam reportable using the eye codes:
 

The policy further specifies what constitutes a comprehensive versus an intermediate exam: "A comprehensive examination consists of eight or more elements, and always includes a fundus examination with the pupils dilated unless contraindicated by the patient's condition. An intermediate examination consists of seven or fewer of the specified elements." The policy even advises coders that "services that require minimal optometric/ophthalmologic examination techniques are included in the evaluation and management codes (99201-99499)."

"Because ophthalmic exam codes were designed specifically to describe the steps involved in performing an exam of the ocular system, we generally find these to be the most specific and accurate," Abel says. But don't automatically assume an eye code is appropriate. The eye code requirements such as those outlined by Noridian Medicare may not always be met when a patient is seen by an ophthalmologist, she adds: "Therefore, it is essential that coders in an ophthalmology practice be comfortable using the E/M codes."

In a final piece of advice to coders, Callaway says that "the amount of reimbursement for eye and E/M codes should not be considered when you are trying to decide what code best reflects the services you rendered."