Ophthalmology and Optometry Coding Alert

How do ophthalmologists decide whether to use E/M codes or eye exam codes for a patient? There arent any written guidelines on this, but we talked to three coding experts to get some tips on deciding which codes to use.

First of all, the documentation guidelines for E/M codes are still in flux. The most recent set was issued in 1997, and had been scheduled to be published in CPT 1999. But they have been withdrawn because there was so much controversy over the numeric formulas -- counting criteria in order to bill for a certain level. For now, providers can use either the 1995 guidelines (the ones published in CPT 1999) or the 1997 guidelines, but they must be in compliance with one set or the other.

(Tip: The 1995 guidelines would only be an advantage to an ophthalmologist if he or she were performing whole body examinations. Otherwise, it is more advantageous to use the 1997 documentation guidelines, because they have the eye exam criteria. With these criteria spelled out, at least youll know what the Medicare auditors will be looking for.)

However, the Health Care Financing Administration (HCFA) has told providers that it will be continuing random prepayment audits based on whichever set of guidelines you choose for your practice. The revised guidelines, expected in late 1999, will include numeric formulas as do the 1997 ones. So many ophthalmology practices have decided to use the 1997 guidelines now.

Historical Note: Up until three years ago, 80 percent of ophthalmological practices used the four eye exam codes only. What happened then? A big change in RVUs for E/M codes -- more money for office visits and consulting and less for surgery. The E/M codes are more lucrative than they were, and, at higher levels, more remunerative than eye exam codes. So, if your clinical actions and documentation can justify it, our interviewees advise going with the E/M codes.

Eye Code Documentation Guidelines Vague

In defining the term comprehensive (used to determine the complexity of an eye exam), the CPT states that such services often include various items. This term means its not mandatory, says Riva Lee Asbell, a consultant in ophthalmology coding based in Philadelphia. While most physicians like the idea of vague documentation guidelines, what has happened is that the Medicare carriers have moved in on this vagueness with their own formulas. More than half the states now have policies for the eye codes, says Asbell. The carriers have definite policies about different elements that are needed. The average policy says that three to seven elements constitute an intermediate exam, and eight or more constitute a comprehensive exam.

Superficially, it seems much easier to comply with the basic rules of the ophthalmology codes than the E/M codes, explains Asbell. But thats because many physicians didnt know that their carriers have come up with policies for the ophthalmology codes, she notes. Check your Medicare carriers bulletin for your state rules.

Documentation to comply with the E/M Guidelines for eye examinations are more extensive if you are using the 1997 version. Asbell recommends that ophthalmology practices should be in compliance with the 1997 edition, because it specifies the requirements for eye examinations.

Use E/M Codes for Medical Eye Problems

We had to review whether we were going to use eye or E/M codes, says Carol Tombre, office manager for Kruger Eye Clinic, a two-ophthalmologist, one-optician practice in Edmonds, WA. We were informed that the ophthalmology codes might be a thing of the past, she says. However, the practice is still using the eye codes because the physicians feel those codes better describe what they do.

So Tombre is only billing the E/M codes if theres a medical problem, she explains. For example, if a patient has keratitis, which would require more follow-up care, an E/M code would be used. If it is a routine refractory problem in a non-Medicare patient, however, the eye codes would be used. (Medicare doesnt cover routine eye exams.) However, if there is a definite medical problem, the E/M code doesnt get edited out, says Tombre, referring to the computer edits that many insurance companies use when processing claims.

The E/M code, Tombre believes, tells the insurance company that there was a medical problem involved. The EOB is less likely to come back with Bill vision, she says. Were leaning towards using E/M codes more because those claims go through more quickly.

The only challenge is that Tombres doctors are more familiar with the ophthalmology codes. At the end of the month, however, when she shows them how many claims have to be re-billed, they arent so pleased. Gradually, they are beginning to warm up to the E/M codes.

Use Eye Codes for Coding Flexibility

Although CPT indicates that any qualified provider may use any of the codes in the eye or E/M section, HMOs sometimes have restrictions. A common restriction is requiring the E/M codes for a medical eye problem and the eye exam codes for a strictly vision care exam.

Sometimes, the eye exam codes are preferable for their flexibility, says Tombre. For example, what if the patient has a vision exam and a medical eye problem? Then we could go either way, she explains. I hear the doctors asking the patients if they have vision coverage.

But often, patients arent aware of what kind of coverage they have, which complicates the issue. Some people dont find out they have vision coverage until theyve already paid for the glasses out of pocket, she says. This is a problem for Tombre, whose practice has an optical shop as well. Patients who werent aware of their benefits ask the doctor to change the diagnosis after the fact -- not only for glasses (when its easier to get reimbursed because a prescription was written), but for the visit as well.

Coding and billing staff arent allowed to change diagnoses, but Tombre does take these issues to the physicians, who will make the change, if appropriate. This is why the flexibility of the eye codes is so valuable to a practice which has an optical shop: if the patient has coverage for vision care, and the eye code was used, the diagnosis can be corrected to go with the vision policy.

The benefit of using the eye exam code instead of the E/M code is that you can go either way, says Tombre. An eye exam code could be either medical or vision, she says. But, if the doctor uses an E/M code, I know its a medical visit, she adds. (Some billers may remember the days when medical insurance included vision coverage. Now vision is usually carved out, if it is covered at all.)

E/M Codes for Minimal and Complex Cases

We stick to the eye codes because theres so much going on with the E/M codes, says Maura Ann Alarcon, office administrator for Jacob S. Plotkin, MD, PA, a two-ophthalmologist practice in Brownsville, TX. But if its a very complicated case and were able to bill one of the higher level E/M codes, well do that, she says. Youd have to get to a level four or five to do it, she says. Alarcon is also using the 1997 documentation guidelines.

For all carriers with an ophthalmology code policy, E/M codes should also be used for minimal services, says Asbell. If you have something quick like a conjunctivitis follow-up, you have to use 99212, she says.

Its important to have some 99212s in your coding profile, Roberts agrees. Medicare expects it. Youre going to have some of those quick re-checks, says Roberts. What else can you use? The intermediate eye exam requires a lot more than what you would do for a typical quick follow-up visit.

Use of 99212 Can Help Avoid Audits

Heres why Medicare expects ophthalmologists to use some 99212s. Medicare created a code crosswalk between eye codes and E/M codes to determine RVUs, says Roberts. This only had to be done for the eye exam codes, because no other specialty has two sets of office visit codes it can use.
To compare which kind of code yields the higher RVU, you have to look further than the levels and the type of exam: you have to consider whether the patient is new or established. For a new patient, they cross walked an intermediate eye exam (92002) to a blend of 99201 and 99202, says Roberts. For a new patient comprehensive eye exam code (92004), they crosswalked 99203 and 99204. For an established patient, they crosswalked 99213 to intermediate eye exam, and for 99214 they crosswalked to 92014. Where is 99212? It doesnt crosswalk to any eye exam code. Thats because for some visits, you are not going to need to perform all the elements of an intermediate eye exam -- such as when you are seeing a patient for a conjunctivitis follow-up on whom you performed a comprehensive eye exam two weeks before.

Audit Tip: If your records show you never provide lower-level services like 99212, this could mark your practice profile as atypical, and flag it for an audit.

E/M and Ophthalmological Codes Here are the relevant codes from CPT 1999 (which uses the 1995 documentation guidelines): E/M Codes: New Patient 99201: Problem-focused history, problem-focused examination, and straightforward medical decision-making 99202: Expanded problem-focused history, expanded problem-focused examination, and straightforward medical decision-making 99203: Detailed history, detailed examination, and medical decision-making of low complexity 99204: Comprehensive history, comprehensive examination, and medical decision-making of moderate complexity 99205: Comprehensive history, comprehensive examination, and medical decision-making of high complexity Established Patient 99211: May not require the presence of a physician 99212: At least two of the following: Problem-focused history, problem-focused examination, straightforward decision-making 99213: At least two of the following: Expanded problem-focused history, expanded problem-focused examination, medical decision-making of low complexity 99214: At least two of the following: Detailed history, detailed examination, medical decision-making of moderate complexity 99215: At least two of the following: Comprehensive history, comprehensive examination, medical decision-making of moderate complexity General Ophthalmological Services New Patient 92002: Intermediate 92004: Comprehensive Established Patient 92012: Intermediate 92014: Comprehensive Intermediate is defined in CPT as an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. It includes history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated. Comprehensive is defined as a general evaluation of the complete visual system. Services need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.