Ophthalmology and Optometry Coding Alert

Ophthalmologists can bill code 92014 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) for routine checks on Medicare patients only if there is a medical problem.

Code 92014 is often used for routine checks when the patient does not have a sign, symptom, complaint or known diagnostic condition for which the physician recommended a re-check. It may be correct for that service, but the service will not be covered by Medicare.

Patients with Vision coverage (usually HMO coverage) are entitled to routine eye care, but patients with medical coverage only are not. If the service will not be covered by Medicare, then an advance beneficiary notification (ABN) form must be signed by the patient. This form essentially states that the patient was made aware that Medicare would likely deny coverage and the patient agrees to pay the service when Medicare denies it.

Check With Carrier to Determine Eye Codes

On the face of it, this may seem simple enough. But it really isnt thats why CPT has a full page of introductory verbiage to these codes explaining what it means. The eye codes (92002, 92004) for new patients call for initiation of diagnostic and treatment program. For established patients, the eye codes (92012, 92014) call for initiation or continuation of diagnostic and treatment program.

Take the example of 92014. What if the ophthalmologist is seeing a patient for a yearly visit who has a stable condition. What kind of diagnostic and treatment program is required to fulfill the requirements for a medically necessary 92014?

There is no national policy in the Medicare program indicating what is required to be performed and documented for any of the eye codes, explains Raequell Duran, president of Practice Solutions, a coding and compliance consulting company specializing in ophthalmology and based in Santa Barbara, Calif. When there is not a national policy, it is the option of the carrier who processes your claims to create what is called a Local Medicare Review Policy (LMRP), she says.

Many carriers rely on the language in CPT that precedes the eye codes, language that says an evaluation of a new or existing condition complicated with a new diagnostic or management problem for intermediate visits 92002 and 92012, and always includes initiation of diagnostic and treatment programs as indicated for comprehensive visits 92004 and 92014.

Its essential that coders check with their carriers to find out if they are using this language to process claims. If youre not sure, contact the provider relations department and ask if they have an LMRP or if they can tell you what the Medicare bulletin numbers are that reference their policy on eye codes.

Justify 92014

But exactly what does the diagnostic and treatment programs language mean, when, for example, you are following a patient with glaucoma whom you see twice a year? What would it take to justify charging a 92014?

Everything including dilatation, says Melodie Aeder, COE, network manager for Andersen Eye Associates of Saginaw, Mich. If the patient came in with no problems, no chief complaint, and just said, Im just here because you need to check the pressure, you would have to charge either a 92012 or a 99213, says Aeder.

"There would need to be more of a problem if you wanted to charge a 92014, she says. Lets say the pressure is elevated, or theres a visual field problem, or the patient needs to be on a beta blocker there are a variety of problems that could justify going to a comprehensive visit.

Aeder adds that some Medicare carriers are doing a lot of prepayment audits now. And her carrier allows only two 92014s per patient a year before asking for more documentation. We want to be very sure before we bill a comprehensive visit that everything is in the documentation, she says.

Evan Malloy, business coordinator for The Eye Center of Menomonee Falls, Wis., notes that the eye codes in general are tricky. Yes, there is a long introduction to them in CPT. But there arent any hard and fast rules about what you need, he says. And he agrees with Aeder that 92014 is not for regular, no-problem follow-ups of known conditions. You cant do a 92014 if youre just checking the patient for pressure, he says.