Ophthalmology and Optometry Coding Alert

Reader Question:

Wake Up to Proper Coding For Exam Under Anesthesia

Question: My doctor saw a 4-year-old in the emergency department (ED) on Friday and did a detailed exam, but because of the patient's age and the extent of his injuries, she decided to do his full exam under anesthesia. She is now coding the detailed ED exam (99283) and the exam under anesthesia (92018). Can we submit both codes, or should we just submit 92018?

Delaware Subscriber Answer: Code 92018 along with 99283 (Emergency department visit for the evaluation and management of a patient, which requires an expanded problem-focused history and examination, and medical decision-making of moderate complexity). CPT places 92018 (Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete) under "Special Ophthalmological Services," which you may report in addition to the general ophthalmological services or E/M services.

Remember: When performing an exam under anesthesia for a Medicare patient, the service of gonioscopy (92020) is bundled as a component of 92018.
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