Ophthalmology and Optometry Coding Alert

Sometimes the question of whether to use E/M codes or eye exam codes has no clear answer when youre coding a claim. But all of the coding experts interviewed say that it clearly pays to use the E/M codes, and not the eye exam codes, when you are doing a gonioscopy, serial tonometry, or a sensorimotor examination. The main reason is that Medicare has bundled these three procedure codes together with the eye exam codes. That means that if you use the eye exam codes when you perform one of these three procedures, you will not get paid for them -- you will only be reimbursed for the eye exam. However, if you use the E/M codes, you will be paid for an office visit, plus the procedure.

For example, the RVU for gonioscopy (92020) is 0.67, and the Medicare national average allowance is $25, according to Healthcare Consultants 1998 Physicians Fee & Coding Guide. If you do a gonioscopy and use the eye exam codes instead of the E/M codes, you will be losing that $25 on each of your Medicare patients, our sources say.

Note: In April 1998, the Health Care Financing Administration (HCFA) announced that 92020 (gonioscopy), 92100 (serial tonometry with multiple measurements of intraocular pressure over an extended time period, same day), and 92060 (sensorimotor examination with multiple measurement of ocular deviation) would be bundled with the eye exam codes retroactive to January 1, 1998. The Healthcare Consultants national average allowance for 92100 is $43; for 92060 it is $33; for 92020 its $25.

(Tip: Some carriers need to be reminded that serial tonometry (92100) is not the one-time pressure check which is done with routine eye exams. The serial aspect comes into play during an examination for suspected glaucoma, for example, when you need several pressure determinations over an extended period of time, on one day.)

The eye exam codes are 92002 and 92004 (new patient), and 92012 and 92014 (established patient). The E/M codes are 99201 - 99205 (new patient) and 99212 - 99215 (established patient).

We do gonioscopies quite often, so we needed to change to the E/M codes, says Robin Fox, director of reimbursement for Eye Centers of Florida, a 30-provider multi-office practice based in Ft. Myers. However, Fox has always used both the E/M and eye exam codes (in various instances), so the change has been a little easier for her than it may be for practices who have never used the E/M codes.

Fox explains it would be possible to go to a higher level E/M code (and thus get paid more) if appropriate documentation is provided. However, usually when a gonioscopy is done with an examination, a level three E/M code is used in her practice, says Fox. A level three E/M code is roughly equivalent to a comprehensive eye exam code, depending on whether the patient is new or established -- so level three might not seem like such a great deal. But it is, because even if we only get a level three reimbursement, we can get a gonio reimbursement as well, says Fox.

(Tip: To be reimbursed optimally when performing a gonioscopy on the same day as an exam, attach a -25 modifier on to the E/M service code so that the gonioscopy will not be bundled into the visit code. Modifier -25 is to be used when a significant, separately identifiable procedure is done on the same day as the office visit.)

Payup: Big Difference

Here is why it really makes a difference to use the E/M codes instead of the eye exam codes when doing a gonioscopy. When billing a level three office visit, you are not only reimbursed for the actual visit (Medicare national average for: new patient [99203] $73; established patient [99213] $41), but also for the gonioscopy (92020 - Medicare national average $25). So, your total reimbursement could be from $66 to $98 -- depending on whether you are billing for a new or established patient.

Compare this to the eye exam codes where you can only be reimbursed for the exam itself (since the gonioscopy fee is bundled with the eye exam code). These codes have a Medicare national average for 92002 (intermediate eye exam for a new patient) of $51; for 92004 (comprehensive eye exam for a new patient) of $83. For 92012 (intermediate eye exam for an established patient) the average is $41; and for 92014 (comprehensive eye exam for an established patient) it is $61.

Also, if you are using consultation codes, the reimbursement is even higher: $102 for a level three (99243). And it is quite conceivable that the exam done with the gonioscopy would go to a level four consultation: $144 (99244).

The numbers tell the story; if you are performing a gonioscopy, serial tonometry, or a sensorimotor examination on a Medicare patient, the E/M codes are better financially than the eye exam codes. Every time you do one of these ancillary procedures and code for an eye exam, you will be losing money unnecessarily.