Ophthalmology and Optometry Coding Alert

If the patient presents with no complaints, you must consider the exam 'routine.'

With 18 plus options to sift through when coding a glaucoma visit, you need these simple guidelines to secure the insurer preferred code that lands payment, not denial.

You have four options for coding glaucoma exams, depending on the payer, type and severity of the glaucoma. You are given a choice of using four ophthalmic visit or CPT codes (or "eye codes") (92002-92014, Ophthalmological services: medical examination and evaluation ...), 10 evaluation and management (E/M) codes (99201-99215, Office or other outpatient visit ...), two HCPCS S codes (S0620 and S0621, Routine ophthalmological examination including refraction ...) and two G codes (G0117 and G0118, Glaucoma screening for high risk patient ...), or possibly, a combination of these.

Hidden trap: You cannot use any combination of these on the same day, experts warn. In coding any patient/physician encounter, your main goal is to bill a code that reflects the type of chief patient complaints or reason for the office visit, and the amount and difficulty of the work done by the doctor.

Tip 1: Apply S Codes for Routine Exams

S0620 and S0621: If a glaucoma patient presents to an ophthalmologist's office for a check up and has no complaints about his eyes (even with the doctor's intensive questioning), then this is a routine exam, no matter what the ophthalmologist finds wrong with the patient. If the patient had no complaints, no matter how minor, the exam is considered routine. "S codes cannot be reported to Medicare and are usually codes specific to BC/BS payers," says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City. "However, BC/BS must also accept the 'eye' codes and E/M CPT codes."

Report routine exams with the HCPCS S codes (S0620 for a new patient and S0621 for an established patient). A routine exam that uncovers cataracts or pressures in the 40s is still routine if the patient had no complaints, concerns, or previous diagnoses of significant eye problems, says David Gibson, OD, FAAO, an optometrist practicing in Lubbock, Texas. However, you should list the diagnoses as secondary on the claim form.

Tip 2: Go to G Codes for Medicare Exams

For Medicare patients, use Medicare's G codes (G0117 for a screening furnished by an optometrist or ophthalmologist, G0118 for a screening furnished under the supervision of an optometrist or ophthalmologist) for patients with no personal history or diagnosis of glaucoma, but due to the patient's age, race, and family history are considered at risk for glaucoma.

This is not a routine exam but is considered a screening exam, as the patient meets the criteria for early glaucoma screening and is concerned about the health of their eyes without any current symptoms.

V-code benefit: For a screening, report G0117 or G0118 with ICD-9 code V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma). You should still report the "V" code as your primary code for a patient who presents for glaucoma screening ifglaucoma is found. Report code 365.x (Glaucoma) as your secondary diagnosis if the ophthalmologist finds glaucoma during the exam.

Keep in mind that the correct "G' code to report depends upon who performed the screening. When reporting the service performed by an ophthalmic tech, (G0118), the ophthalmologist or optometrist must provide supervision.

Don't miss: Keep in mind that Medicare only G codes are bundled with E/M and eye codes. It would be rare for a patient to report to your office for the purpose of a glaucoma screening only, experts note. Therefore, your physician is more likely to perform a complete ophthalmic evaluation which may include glaucoma screening and should be coded with the appropriate level of E/M or eye code.