Ophthalmology and Optometry Coding Alert

To get an accurate handle on where your coding stands compared to others in your specialty across the country, it can be a good idea to review national benchmarking data. Frank Cohen, director of analytics and business intelligence at Doctors Management, shared the averages for each specialty during his Jan. 16 presentation, “Risk-based Auditing: New Tools and Techniques.”

Check out the top five CPT^® codes reported by eye care providers in 2019, based on CMS data. Surprisingly, although ophthalmologists and optometrists share two of the same top-billed codes, that’s where the similarities end. Otherwise, the two specialties had separate coding trends, so we’ve outlined a few tips for both specialists in reporting their most-billed codes.

Here Are Ophthalmology’s Top 5

Ranking first is 92014: Ophthalmologists reported 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) on 13.67 percent of all claims last year, the data indicated.

Remember that this code applies to a comprehensive exam, and payers will outline what they require before you can consider a visit to be “comprehensive.” Typically, you’ll need to perform a general exam of the patient’s visual system and initiation of a diagnostic or treatment program, in addition to meeting other, more detailed criteria.

92134 ranks second: Code 92134 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina) was reported on 10.14 percent of ophthalmologists’ Medicare claims last year, the data noted.

This test is inherently bilateral, so the reimbursement you collect for the code accounts for what is involved in scanning both eyes. Therefore, when your eye care physician performs the scan bilaterally, you should only report the code once. Do not report 92134 either on two lines — one line with modifier RT (Right side) appended and the other line with LT (Left side) appended — or on one line with modifier 50 (Bilateral procedure) appended.

In addition, 92134 has a bilateral modifier indicator of “2” in Medicare’s Physician Fee Schedule. This means that the usual bilateral payment adjustment does not apply. Medicare (and payers who follow Medicare rules) will only reimburse the allowable amount for a single code or one unit of service.

Ranking third is 92012: Ophthalmologists reported 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) on 8.38 percent of all claims last year.

Tip: You should never report 92012 with 99173 (Screening test of visual acuity, quantitative, bilateral), 99174 (Instrument-based ocular screening [eg, photoscreening, automated-refraction], bilateral; with remote analysis and report), or 99177 (Instrument-based ocular screening [eg, photoscreening, automated-refraction], bilateral; with on-site analysis), CPT^® states. That’s because these services are inherently part of 92012, and it would therefore be considered “unbundling” to try and report them together.

67028 ranks fourth: Ophthalmologists submitted 67028 (Intravitreal injection of a pharmacologic agent (separate procedure)) on 5.7 percent of claims last year, according to CMS data.

This eye drug injection code should always be reported along with the HCPCS codes for the drugs you’ve injected. For example, the ophthalmologist injects 20 mg of Kenalog. Report 67028 and then J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) with “2” in the “units” column of the claim form. This way you’ve collected for both the injection service (67028) and the drug you injected (J3301 x 2).

Ranking fifth is ophthalmoscopy code 92226: You may recall that CPT^® deleted 92226 (Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent) effective Jan. 1, 2020. However, it was still in effect last year, when ophthalmologists included it on 3.87 percent of claims.

Even though 92226 is gone, you can still report extended ophthalmoscopy with 92201-92202 (Ophthalmoscopy, extended …), which debuted this year. The new codes have more extensive descriptors as compared to the old ones, noting a wider variety of potential conditions that the services treat, and also illuminating the fact that the same codes apply whether the physician is treating one eye or both. Therefore, the descriptors make it clear that there is no need to report two units of the code or to append modifier 50 (Bilateral procedure) if you treat both eyes.

Check out the Top 5 for Optometry

Ranking first is 92014: This is not only the top-billed code by ophthalmologists, but it also ranks first for optometrists, representing 13.81 percent of all claims reported to Medicare in 2019.

92015 takes a close second: Reported on 10.68 percent of claims last year, 92015 (Determination of refractive state) is next most common for optometrists.

Because neither the ophthalmological services codes nor the E/M codes include refraction, some practices charge for refraction using 92015, but many insurers consider refraction non-payable, unless they have a separate vision plan that will pay for it. If you verify the patient’s insurance and find that refraction isn’t covered, you should issue the patient an advance beneficiary notice (ABN) before you perform the service so the patient knows they are responsible for the charge.

Coming in third was 99213: Optometrists reported E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…) on 5.32 percent of claims last year, the data noted.

When choosing between 99213 and 99214, pay attention to the differences in the descriptors, which we’ve bolded:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient›s and/or family›s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.)
• 99214 (…a detailed history, a detailed examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.”

Remember that you need two out of three elements to report the service, unless you’re billing based on time. So, if your documentation reflects a detailed history, an expanded problem focused examination, and low complexity medical decision making, the right code is 99213 and not 99214, despite the detailed history.

92250 takes fourth slot: Optometrists reported 92250 (Fundus photography with interpretation and report) on 5.32 percent of claims, matching the frequency of 99213 (above).

Most insurers will not reimburse you for fundus photography if you perform it on a healthy patient, since this service typically applies to patients with retinopathy.

“Fundus photography will be covered if accompanied by fluorescein dye angiography when used to evaluate abnormalities or degeneration of the macula, the peripheral retina or the posterior pole,” says Part B MAC First Coast Service Options in its policy for this code. “Fundus photography may be covered as a stand-alone procedure, without fluorescein dye angiography, following recently performed nonsurgical or surgical treatment for macular pathology.”

92012 ranks fifth: Also appearing on the ophthalmology list, code 92012 was reported on 4.82 percent of Medicare optometry claims in 2019. Keep in mind that you should only report this code for established patients and never for patients who are new to your practice.