Ophthalmology and Optometry Coding Alert

Question: When we see a confirmed glaucoma patient who needs to have follow-up appointments, how should we code for the subsequent visits?

Iowa Subscriber

Answer: Ophthalmologists often have to follow-up with glaucoma patients because of medications or postsurgical concerns. Many practices differ in their coding method for follow-up visits, using either E/M or eye codes. Both sets are acceptable as long as they accurately depict the service. The decision usually depends on the physician's preference. Some practices choose the eye codes because they require less documentation.

Some coders recommend using E/M codes when the physician performs a vision and pressure check and the pressure is high enough that it requires multiple checks, but using the eye code 92012 (Ophthalmological services ...) when an external examination is performed. The use of the eye code, 92012, depends on the requirements listed in LMRP for your area.

In documenting follow-up glaucoma visits, be sure to always document a chief complaint even if it is simply "follow-up glaucoma."

Advice for You Be the Coder and Reader Questions provided by Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.