Ophthalmology and Optometry Coding Alert

Report general ophthalmologic codes when they best describe the service

When your ophthalmologist examines and evaluates a patient in your office, you've got some coding choices to make. You can report an E/M code (99201-99215), or you can choose an eye code (92002-92014).
 
The choice becomes difficult when there is a code in both series to describe the physician's work. Picking the right code to report an eye exam depends on exactly what the ophthalmologist examines and his reasoning.

Check Out Documentation First

CPT instructions tell you that you should pick the code that most clearly describes the service your ophthalmologist performs.

Note: There is no mandate that states that you must use the ophthalmology codes instead of the evaluation and management codes.

Experts warn: Avoid the temptation to code the office visit based on the highest relative value unit (RVU). If the physician is strictly evaluating the function of the eye, you should report an eye code (92002-92014). If, however, the ophthalmologist is evaluating the eye as related to a systemic disease process, report the appropriate E/M code, says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.

How it works: If a patient comes in for what he often refers to as his "yearly" exam and he has no complex medical problems, you would use the eye codes, says Rita Knapp, CPC, chief compliance officer and senior billing specialist at Abrams Eyecare Associates in Indianapolis. If a patient comes in for a brief or simple visit for a specific problem or a very complex set of problems, use the E/M codes, she says. "The final choice would depend on the presenting problem(s), management options, and degree of medical decision-making."

Example 1: A new patient presents complaining of blurred vision (368.8, Other specified visual disturbances). The ophthalmologist performs a comprehensive examination, including checking the patient's visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure. Since this is strictly an examination of the eyes' function, you should report 92004.

Example 2: A patient with chronic blepharitis (373.00, Blepharitis, unspecified) comes in due to a recent foreign-body sensation. During the case history, the patient mentions a recurring headache (784.0, Headache). The patient had an unremarkable comprehensive exam four months ago, and you don't think it's necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye (930.0, Corneal foreign body). Refraction indicates a significant increase in hyperopia (367.0, Hypermetropia), which may explain the headache.

You can report an E/M code -- as long as you meet the higher standard of documentation for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined in the E/M codes that are not specified in the eye codes. Many carriers look for an E/M code if there is a medical diagnosis.

Pointer: Make sure your physician keeps good, detailed documentation. The information in the documentation is what will lead you to choose the correct code.

Take Carrier Differences Into Account

The eye codes, like the E/M codes, are divided into new patient (92002 and 92004) and established patient(92012 and 92014) classifications, which are further broken down by their level of service.

Unlike the E/M codes, the eye codes have only two levels of service, intermediate and comprehensive, making it easier to determine the level of service that your ophthalmologist has provided to a patient. Use the chart on page 83 comparing the components of intermediate and comprehensive eye codes to help delineate between the two.

Tip: Note that the comprehensive level of the eye codes (92004 and 92014) includes "one or more visits." An example of this would be a patient whom the ophthalmologist sees, and the physician determines the need to do a dilated exam. However, the patient wants to wait until Friday afternoon to have this portion of the exam done so the resulting effects will not interfere with work. You could not separately bill for the patient's return visit to the office for the dilated exam to complete the encounter. 

Caution: Your CPT manual has definitions of "intermediate ophthalmological services" and "comprehensive ophthalmological services." Be careful, however: Individual carriers have refined those definitions even further. In fact, most carriers have a local coverage determination (LCD) policy for general ophthalmologic services that require a specific number and type of exam elements, testing and history that must be performed in order to assign the specific levels of the eye codes.

It is not appropriate to perform the services in order to meet the level of code assignment. As with the E/M codes, the components of the office visit encounter must be considered medical necessary for the presenting problem of the new or established patient. Many private payers have adopted these policies as well.
 
If you don't meet your carrier's definition of "intermediate" or "comprehensive" eye exams, you should report an E/M service code instead of an eye code. The intermediate level requires a new problem or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis.

Smart step: Check your carrier's local coverage policies for specific guidelines.

"The carrier should not make a difference, but it definitely does," Knapp says. "Vision plans will only accept eye codes. Many other carriers automatically deny the claim as 'routine' if they see eye codes, even with a medical diagnosis. It's a never-ending battle to explain to the carrier that just because it is an eye code does not make the service routine and therefore noncovered."

Don't Rule Out Modifiers

Medicare and most other carriers treat the eye codes the same as E/M codes. Therefore, if there is a separately identifiable E/M service, you can report it with an eye code and append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery).

Remember: Medicare released Transmittal 954, dated May 19, 2006, that states you don't have to append modifier 25 on the E/M or eye code service when the physician performs the service on the same day as a procedure with zero global days.

However, private payers may still require modifier 25 or 57, regardless of zero, 10 or 90 global days. For further details, view the Medicare transmittal on the CMS Web site (www.cms.gov).

Reminder: You can't report one of each. The National Correct Coding Initiative (NCCI) lists eye codes 92002-92014 as "mutually exclusive" of most E/M codes, meaning you can't report them together. Both sets of codes describe office visits, and you have to choose either an E/M code or an eye code to report.

Chapter 11 of the National Correct Coding Policy Manual for Part B Medicare carriers makes the comparison official: "When evaluation and management codes are reported, these general ophthalmological service codes ... are not to be reported; the same services would be represented by both series of codes." That means you can report either an E/M code or an eye code.