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, not even a change of medication, you could probably only bill a 99212 or 99213 depending on what is done in the examination, or change to a lower-level E/M, she says. The medical decision-making just isnt there. If you have to consider different diagnoses, a change in medication, the ordering of tests or other factors that influence medical decision-making, and if the exam is more in-depth, you could bill a higher-level E/M code. These criteria for billing higher-level E/M services are why many coders opt for the more vague eye codes instead, Mac says.

While the documentation requirements for the eye codes are at the local Medicare level, the E/M require-ments are at the national level, Duran says. That means E/M documentation requirements are standard across the nation, and the guidelines for E/M documentation are much more detailed than those for the eye codes. In addition, the E/M codes are subject to mandatory, random, prepayment review by the carriers, Duran says. The eye codes are not, making them easier for the ophthalmologists to use.

Document the Chief Complaint

Many patients must return three or four times a year for followup visits for chronic conditions. The visits get paid based on what was documented in the previous visit, not on what the patient presents with at the current visit.

For example, in January a Medicare patient goes to her ophthalmologist because she feels she should have a checkup. She has no complaints, says she sees well and feels fine. The examination performed that day, however, reveals slightly elevated intraocular pressure (365.01) and suspicious optic disk cupping (365.01). This could be a sign of glaucoma, and the physician must evaluate the patient further and perhaps prescribe medication. Still, the visit is not payable, because the reason for the visit did not substantiate medical necessity. Medicare only covers those visits where the history reflects a medical reason for the visit in the form of a chief complaint with a sign and/or symptom, a reported known medical condition or physician-recommended return based on a medical condition.

But when the patient comes back in April for a followup visit the first of many it will be payable, providing that the documentation for the initial January (non-billable to Medicare) visit says the patient was a glaucoma suspect based on the findings of the intraocular pressure (IOP) and optic disk cupping and that the patient was asked to come back in three months for a followup visit. Because the HCFA/AMA documentation guidelines say that each visit should stand on its own for continuity of care and payer auditing, it is also necessary to indicate in the history of the followup visit that the chief complaint (reason for this encounter) is for a followup of suspected glaucoma. This should be the first entry in the history after which any other patient-reported information is recorded.

Documentation in the first visit is crucial. The physician or technician must indicate in the chart that the patient needs to be seen at a certain interval for a followup visit. Do not write, Patient must be seen every four months for check. You can only document when the next visit must be. Medicare does not allow standing orders for regular visits or tests.

Examples of other silent problems in addition to glaucoma that may be picked up by the physician but not presented as complaints by the patient include diabetes, corneal edema due to contact lens wear, various types of nerve palsy, early cataracts and early age-related macular degeneration.

The same thing is true for cataracts or diabetes. When the physician first notices the beginning of cataracts, he or she discusses it with the patient and says yearly checks will be necessary, says Linda Taylor, office manager for the Cascade Eye Center in Dalles, Ore. The reason for the patients return is established at the last exam. Whether its a cataract, glaucoma or diabetes check, that should be the chief complaint for the next visit.

Examples of Chronic Conditions Chronic conditions that may require periodic followup visits include the following: Diabetes with ophthalmic manifestations 250.5x Glaucoma 365.0-365.9 Long-term (current) use of other medications V58.69 Following completed treatment with high-risk medications, not elsewhere classified V67.51 Cataract 366.0-366.9 This is by no means a complete list. Certain vascular conditions, degenerative conditions and other problems