Ophthalmology and Optometry Coding Alert

There's no simple answer to find which code to use, but documentation will drive your choice.

Although coding office visits is pretty straightforward for most other specialties, ophthalmologists and optometrists have two options when reporting these visits. Codes 92002-92014 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program...) specifically describe ophthalmological services, but eye care specialists are free to use E/M codes (99201-99215) as well.

How does a coder know which code set to use in which scenario?

Read the Notes Thoroughly

Some practices have internal guidelines that dictate when they use eye codes vs. E/M codes, while others make the decision on a case-by-case basis or leave it solely in the physician's hands. In reality, the best method your practice can use is reviewing the documentation and making that your guide on which codes to report.

"We use auditing tools – starting with the chief complaint and history of present illness to start the ball rolling," says Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology in Canandaigua, New York. "Then we go from there based on what elements are completed, what elements are missing, etc., to decide which code set is better to fit the situation."

You'll find that certain codes have more stringent guidelines and bullet points that need to be met than others, Vanderwall says. "For example, we rarely use an E/M code for a routine eye exam. However, we do sometimes use eye codes when evaluating chronic medical conditions. Again, it's based on the individual documentation within each record, medical necessity for the visit at-hand, etc. A lot comes into play."

Watch for this:  Some payers will not pay for general routine vision exams unless covered under the insured's policy and in some cases, the eye codes can be submitted just once annually. So, for some patients, submitting the eye codes for problem visits more than once per year may pose a problem for payment. Payers may simply have policies in place that direct physicians on which codes may be used – E/M or eye codes – dependent upon the reason for the visit.

Know What It Means to "Initiate Diagnostic and Treatment Program"

Remember that the eye code descriptors all contain verbiage describing a medical examination and evaluation with "initiation of" (in the case of new patients) "or initiation/continuation of" (for established patients) a "diagnostic and treatment program."

Although CPT^® doesn't specifically explain what it means by "diagnostic and treatment program," most insurers will list their requirements. For example, Blue Cross Blue Shield of Rhode Island says in its policy, "Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self-limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be reported using 92002-92014. A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014."

Keep in mind that the BCBS policy is just one example - be sure and ask your payer for its specific requirements.

Differentiate Intermediate From Comprehensive

If you meet the requirements to report the eye codes and the documentation supports them, you'll want to determine whether the physician performed an intermediate (92002/92012) or comprehensive (92004/ 92014) service. Although CPT^® doesn't break down the levels, the AMA did cover them in the Sept. 2002 issue of CPT^® Assistant, as follows:

• Intermediate: "Includes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated, including the use of mydriasis for ophthalmoscopy."
• Comprehensive: "Includes a general evaluation of the complete visual system and may constitute a single service entity but need not be performed at one session. The comprehensive service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, basic sensorimotor examination and, if indicated, biomicroscopy, examination with cycloplegia or mydriasis, and tonometry as well as the initiation of diagnostic and treatment programs."

Therefore, if your documentation supports an eye code, refer to these criteria to ensure that you've selected the correct level.

Make Sure Documentation Is Solid

No matter which code you use, documentation requirements must be met for both the eye codes and the E/M codes to support the reason for presentation and any details needed to describe the reason. An appropriate exam will follow based on the patient intake information, followed by the treatment plan and diagnosis. The exam elements must be medically necessary based on the presenting problem.

E/M codes have national coding guidelines that detail the documentation necessary to support a given level of service (such as 99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...).

The guidelines describe each service level's national Medicare required amount of history, examination, and medical decision making (HEM). Only medically necessary performed and documented items count toward an area. Eye codes do not have those HEM requirements and are not subject to mandatory auditing.

Money can be the differentiator: If your audit of the documentation reveals that the physician can select either an eye code or an E/M code, compare the reimbursement of the two codes. For instance, if your documentation supports both 92012 and 99213, most coders will choose to report 92012, since it pays about $13 more.

For a complete breakdown of the eye codes and E/M codes, see our "clip and save" on page 91.