Ophthalmology and Optometry Coding Alert

For optimal reimbursement, use the established patient, general ophthalmological services codes (92012-92014) for followup visits with patients who have chronic conditions. If the condition is exacerbated by an acute problem, use the evaluation and management (E/M) services codes (99212-99215). Technically, you can use either when billing Medicare, depending on the documentation, says Heather Loveland, CPC, president of Physicians Advantage, an ophthalmology coding and compliance consultancy in Hendersonville, Tenn.

Use the eye codes when your documentation meets the criteria in the local medical review policy (LMRP). If the carrier does not have an LMRP, refer to the CPT notes on general ophthalmological service codes. Use the established patient E/M codes 99212 or 99213 (office or other outpatient visit for the evaluation and management of an established patient) if your documentation does not meet the criteria for the intermediate eye code.

Ophthalmologists and optometrists check patients frequently to evaluate the status or progression of a condition such as diabetes, glaucoma, incipient cataracts or other problems. These visits can occur at a frequency of between three and 12 months depending on the condition and progression of disease. It can be confusing to decide whether to use E/M services codes or the eye codes when billing these types of services.

Code 92012 or 92014 is more appropriate (than E/M codes) because they best describe what youre doing, says Susan Callaway, CPC, CCS-P, an independent coding auditor and educator in North Augusta, S.C. These codes (92012-92014) are meant for an evaluation of the function of the eye. The higher E/M service codes are for more acute medical conditions.

The eye codes also reimburse at higher rates. It is more beneficial to use the eye codes when the patient is seen for followup of a chronic condition that is stable, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consultancy based in Santa Barbara, Calif. This is because if you used an E/M code, the documentation most likely would not qualify for a higher level of service, based on history and medical decision-making.

For example, the cataract patient who has no vision changes and no other complaints requires only a brief history of present illness and low-complexity medical decision-making. If you used an E/M code, you could only bill for a 99213, regardless of the fact that you provided a comprehensive examination. If you used an eye code, however, you could appropriately bill 92014, which pays more.

The E/M codes will not pay as much as the eye codes in evaluating a patient with a stable, chronic condition, says Margaret Mac, CMM, CPC, administrator of the Florida Eye Center in St. Petersburg, Fla. If a patient has glaucoma with no changes, [...]