Ophthalmology and Optometry Coding Alert

Question: Which code should we report for evaluation of diabetic retinopathy and glaucoma? We can’t decide whether it should be 99212 or 99213, but the ophthalmologist actually marked 99214.

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Answer: This question highlights a common myth — that each type of diagnosis has a standard evaluation and management (E/M) code associated with it. However, your E/M code should be based upon what the documentation supports, which can differ greatly even with the same diagnosis. A patient with diabetic retinopathy and glaucoma may have other chronic conditions, taking the complexity quite high, or the patient may simply be presenting for a routine pressure test, which would make it lower.

Therefore, you should scrutinize the history, exam, and medical-decision making documented in the record to select the appropriate E/M code and only report that with your claim.