Ophthalmology and Optometry Coding Alert

Plus: Know which visits have a medical element.

Unlike other specialties, eye care professionals have the distinct advantage of being able to choose between two sets of codes when evaluating patients in the office setting. Although there are myriad advantages to this, it can also become challenging when deciding which code set to use on your claims.

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.

Here’s the Challenge

There is no set rule regarding when to use the E/M codes or the “Medicine” section codes. Before you select which code to use, you should first familiarize yourself with what each code describes and what the insurance policies are on each set, says Aida Marquez, CPC, coder with Medical Consults. “Choose the appropriate codes according to the service provided,” she says, pointing to the following options:

• General ophthalmological service: New patient (92002-92004)
• General ophthalmological service: Established patient (92012-92014)
• E/M codes: New patient (99201-99205)
• E/M codes: Established patient (99211-99215)

You’ll typically use the general ophthalmological exam codes when the eye care physician’s examination focuses on eye function, Marquez says. “The general ophthalmological codes are appropriate for services provided to new or established patients when the level of service includes such routine ophthalmic examination techniques as slit lamp exam, keratometry, ophthalmoscopy, and retinoscopy.”

If, however, the physician doesn’t launch a treatment or diagnostic program, you may be better off using the E/M codes, she says.

Check Payer Policies

Individual insurers may post policies outlining when you should use the ophthalmological services codes and when E/M codes are preferred. In addition, your insurer might note when to use the intermediate ophthalmological services codes versus the comprehensive ones. For instance, Aetna’s policy makes the following specification:

“The comprehensive services include a general examination of the complete visual system and always include initiation of diagnostic and treatment programs … These services require that the patient needs and receives care for a condition other than refractive error. They are not for screening/preventive eye examinations, prescription of lenses or monitoring of contact lenses for refractive error correction (i.e. other than bandage lenses or keratoconus lens therapy). There must be initiation of treatment or a diagnostic plan for a comprehensive service to be reported. An intermediate service requires initiation or continuation of a diagnostic or treatment plan. Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014.”

Aetna offers the example of a patient who presents with allergic conjunctivitis controlled by over-the-counter antihistamines. The patient comes in for a preventive visit, which “should not be reported using 92002-92014,” Aetna notes. In this case, the insurer prefers that you instead report an E/M code as appropriate, based on the documentation.

In actuality, billing the general ophthalmological service codes requires initiation or continuation of diagnostic procedures, and initiation or continuation of treatment programs (depending on the code selection). Also, diagnostic tests may include a refraction, visual field test, radiology, or lab work, and treatment programs may include prescribing medications or lenses, scheduling or performing surgery, coordinating treatment with another physician or facility, and patient education.

Get to Know the Nuances

Marquez offers the following recommendations to coders who are working to differentiate between code sets in the absence of payer guidelines:

• Eye codes are more restrictive as to which diagnoses meet medical necessity, and the specific codes can vary by payer, whereas E/M codes don’t typically have the same restrictions.
• Use E/M codes for visits that have a medical element. “If the exam is strictly visual and contains no medical elements, an eye code is the right choice.”
• Eye codes have frequency edits. “For example, you’re limited to billing code 92014 once per 12-month period per patient. E/M codes don’t share those same frequency edits.”
• Verify payer guidelines. “While the documentation requirement for E/M codes is standardized across most payers, the required documentation for eye codes may vary.”
• If you meet the required elements for both an eye code and an E/M code, choose the code with the highest level of reimbursement, but not both.

In addition, remember that in some cases, payers might reimburse 92002-92014 under the vision benefit, but would pay the E/M codes under the patient’s medical benefit. This might trigger different copays or deductible amounts, so pre-verify all coverage rules before patients present for their appointments.