Ophthalmology and Optometry Coding Alert

Question: An established patient came into our office with glaucoma and received evaluation and care. During the same visit, we decided to do a refraction. How should I code this combination of procedures? Will I get paid for both services?

Pennsylvania Subscriber

Answer: From the information you have provided, it sounds as if your first step is to code for the general patient evaluation using either an established patient eye code, 92012-92014, or an established patient E/M code, 99212-99215, depending on the patient's presenting problem and the physician's documentation. Link this procedure code with the appropriate 365.xx glaucoma diagnosis code. For the refraction, you should use 92015 (Determination of refractive state), but you must be sure to link it to diagnosis code 367.9 (Unspecified disorder of refraction and accommodation).

The patient may be stuck paying for the refraction, depending on his plan, so be sure to check with his payer so you can discuss potential payment issues with him before the procedure. If he has an HMO, he might be covered for both services, but, unfortunately, Medicare will only cover the office visit for the patient's known chronic glaucoma.