Ophthalmology and Optometry Coding Alert

Which codes should ophthalmologists use for office visits, evaluation and management (E/M) codes (99201-99215) or eye codes (92002, 92004, 92012, and 92014)? As the Health Care Financing Administration (HCFA) begins pilot-testing the new E/M guidelines, ophthalmologists continue to use either the 1995 or the 1997 guidelines if they are using the E/M codes. But the question concerning whether to use the E/M codes or the eye codes continues.

Difference Between E/M and Eye Codes

The E/M codes are sick visit codes, for patients who have a problem, says Heather Loveland, CPC, president of Physicians Advantage, a Hendersonville, Tenn.-based company that bills for 60 optometrists and three ophthalmologists. We use the eye codes for routine eye health yearly exams, she says. But its true that some practices use the E/M codes for routine exams, too. From a Medicare perspective, of course, this isnt relevant because Medicare doesnt pay for routine exams. But for commercial plans, PPOs and HMOs with vision riders, there often is a difference, says Loveland. The vision riders usually require the eye codes whereas the medical portion of the plan requires the E/M codes.

The Documentation Difference

Another big difference is documentation. The documentation is much less extensive with the eye codes than with the E/M services codes, Loveland notes. The examination bullets are associated with the E/M services codes in most instances (although in some states with the eye codes as well), while guidelines for the eye codes are primarily much less stringent for the history and medical decision-making requirements.

Local Medicare carriers, not CPT and HCFA, establish the documentation requirements for the eye codes. In fact, CPTs documentation requirements for the eye codes are very loose. The Medicare carrier in Tennessee has set guidelines for the eye codes that include a list of 10 areas to examine.

1. confrontation visual field
2. ocular motility
3. cornea
4. lens
5. retina (including vitreous, macula, periphery,
vessels)
6. eyelids and adnexa
7. pupils and iris
8. anterior chamber
9. intraocular pressure
10. optic disk

The number of areas you examine determines whether the eye exam is intermediate (92002, 92004) or comprehensive (92012, 92014). In Tennessee, for example, a comprehensive examination includes eight or more elements. A dilated fundus exam must be done as well, says Loveland, unless the patient refuses. In that case, the refusal must be documented as well. Performing seven or fewer elements would be billed as an intermediate exam.

She adds, however, everyone should review their Medicare fee schedule for 2000. In some geographic areas the comprehensive eye codes (92004 and 92014) are reimbursed higher than the level four E/M codes (99204 and 99214). In our area (Tennessee), its amazing how much the increase was in the E/M codes, she says. So a lot depends on the presenting problem of the patient. If a patient has a problem, it may be to your advantage to use the E/M codes, adds Loveland.

A lot also depends on how good your documentation is. Some practices are using the eye codes because the documentation is so much easier.

The physicians arent getting the sufficient documentation to support a high level E/M code, says Betty Torres, CPC, manager for patient accounts in the department of ophthalmology at the University of Texas medical branch in Galveston. We give the clinic feedback notes on what to code out, and I meet with the residents monthly on reimbursement issues, she explains. And as far as Texas Medicare goes, I think the reimbursement is better for the eye codes than the E/M services codes. Of course, this also is dependent on which level E/M codes you use. If you generally use a level two, that will not pay any better than an eye code.

Judy Pentecost, CPC, physician coding advocate for the Watson Clinic in Lakeland, Fla., says the three ophthalmologists and two optometrists she bills for almost exclusively use eye codes. They are using these because the documentation requirements are so much easier, she notes. They spend less time counting bullets.

Yes, there is still documentation required for the eye codes, says Pentecost. But the doctors dont have to look at the eye exam and go down through all the bullets. The doctors dont want to do that.

Pentecost is a bit frustrated by this because she bills for 187 physicians and tries to keep telling them how to maximize revenue. Certainly, they would be a lot better off billing a level four than a 92014, she says.

Tip: Dont forget, documentation alone isnt enough. There must be medical necessity as well. The old rule, as Pentecost says, was: If it isnt documented, it isnt done. The new rule is: If the procedure and the medical necessity arent documented, it isnt done.