Ophthalmology and Optometry Coding Alert

The four-year phase-in period for practice-expense relative value units has ended, and ophthalmologist fees are up in the office but, for the most part, down in the operating room. In 2002, office-based eye codes and E/M codes have big increases, but hospital- or ambulatory surgical center-based procedures have decreases. Major procedures with many global-period postoperative visits have fewer reductions than major procedures with only a few postoperative visits.
 
For example, compare 66172 (fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma [includes injection of antifibrotic agents]), which has 12 postoperative visits, to 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]), which has the fewest. The payment for 66172 in 2002 is $1,139, up 17 percent from $974 in 1998, when the phase-in of new calculation methodology began. Cataract surgery, however, dropped 15 percent from $795 in 1998 to $670 in 2002. Procedures with an intermediate number of follow-up visits, such as 67108 (repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique) and 65755 (keratoplasty [corneal transplant]; penetrating [in pseudophakia]), have smaller decreases: 65755 dropped 3 percent from $1,118 in 1998 to $1,084 in 2002, and 67108 dropped 10 percent from $1,605 in 1998 to $1,445 in 2002.
  
Minor procedures performed in the office will have much higher fees  to reflect the ophthalmologist's overhead. For example, 65222* (removal of foreign body, external eye; corneal, with slit lamp) went from $52 in 1998 to $64 in 2002; 65430* (scraping of cornea, diagnostic, for smear and/or culture) from $78 in 1998 to $369 (a 473 percent increase) in 2002; 67228 (destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]) from $790 in 1998 to $847 in 2002; 67800 (excision of chalazion; single) from $87 in 1998 to $148 in 2002; and 67908 (repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection [e.g., Fasanella-Servat type]) from $506 in 1998 to $777 in 2002.
 
The lacrimal probing codes (68801-68840) have been cut drastically; so has 68761 (closure of the lacrimal punctum; by plug, each). This is because of previous errors in the Fee Schedule . These codes included, among other errors, costs for supply for bipolar cautery ($89, not performed during lacrimal probing or punctal plug placement), a shield ($16.50), and paper towels ($15.50).
 
A big error caused 92225 (ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial) to pay more than it should have. The price rose from $30.16 in 1998 to over $60 in 2001. The increase was due to a supply error that reported the cost of four colored pencils and a piece of retinal drawing paper at $54.95. The price has now dropped below the 1998 fee; 92225 now pays $22.44.

The eye exam codes and many office-based diagnostic services have big increases. Code 92002 (ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) now pays $67, compared to $48 in 1998; 92004 ( comprehensive, new patient, one or more visits) pays $123.44 compared to $71.83 in 1998. Code 92012 (ophthalmological service: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) pays $61.18 compared to $41.46 in 1998. Code 92014 ( comprehensive, established patient, one or more visits) pays $91.22, versus $57.56 in 1998. E/M code 99213 pays $50.32. In 1998, it paid $41.46. Code 92083 (visual field examination, unilateral or bilateral, with interpretation and report; extended examination) pays $73.48, compared to $50.26 in 1998; 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report) pays $126.70 compared to $90.99 in 1998, and 92285 (external ocular photography with interpretation and report for documentation of medical progress [e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography]) pays $36.92 compared to $18.34 in 1998.
 
The new fee schedule may make it easier to choose between 99213 and 92012, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and reimbursement consultancy based in Santa Barbara, Calif. In 1998, E/M codes paid better than eye codes. "That's no longer true," she says. "This shows the importance of keeping up with your fee schedule."
 
The schedule's impact depends on case mix. Ophthalmologists will have a net increase of over $200 million a year from the changes, says the American Academy of Ophthalmology. Practices that are entirely office-based will see "huge increases in revenue." But practices that mainly consist of major surgery will see a cut.