Ophthalmology and Optometry Coding Alert

Hint: Choose E/M codes over eye codes for higher pay.

Ophthalmologists who provide low vision rehab are providing a highly regarded and medically necessary service for their patients. But the multiple CPT^® codes available and the documentation required to support those codes can be overwhelming. If you don’t know how to correctly code your low vision exams, you are costing your practice money.

Think positive: Low vision is feeling the squeeze of reimbursement cuts, but if billed correctly, it remains profitable. Why? Exams on patients with visual impairments can usually be leveled higher than typical medical eye exams. Low vision (LV) patients often present with complicated histories and diseases. The ophthalmologist will often need to coordinate referrals to other healthcare providers, and they’ll almost always spend more face-to-face time counseling the patient. Thus, this may lead to a higher coding level — and when documented correctly — can result in higher compensation.

“There are no specific LV examination codes … but then there are no specific exam codes for most medical specialists,” says Thomas Porter, OD, FAAO, director of low vision services at Saint Louis University Department of Ophthalmology. “One should begin by asking ‘How did the patient come to see me today?’ Were they an existing primary care patient? New patient? Referred to you for LV services?” Porter advises. You may choose to use eye codes, E/M codes, and maybe consultation codes when billing the encounter.

Pinpoint These Eye Codes (920xx)

Some physicians choose the eye codes because they are comfortable with them, and the documentation requirements are less stringent. You could choose the eye codes 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits) and 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) for new patients and 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) and 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) for established patients. However the procedural requirements are more rigid, and due to the length of LV appointments, you may be missing out on revenue.

Rely on E/M Codes (992xx)

An LV evaluation has very different content from an ophthalmic evaluation and ophthalmic codes may not accurately reflect the components of the exam. “If a patient is seen for a low vision exam, I suggest you consider E/M codes because [they] give you much more freedom to do LV-specific testing than the [eye] codes,” advises Porter. “The [eye codes] require specific tests used in general eye exam[s] but that often do not help solve low vision problems.” Depending on the components of the exam, you can choose E/M codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).

Keep in Mind 3 Documentation Essentials for LV E/M

Low vision exams are often lengthy and involved, even if they don’t qualify for much more than a low level of complexity. Much of the exam time consists of the doctor counseling and advising the patient, and billing based on time spent counseling could up your reimbursement — as long as the physician thoroughly documents the visit. Bill based on time when the physician spends more than 50 percent of the visit doing things like:

• Educating the patient about their eye condition(s)
• Counseling the patient about treatment options and discussing treatment plans
• Coordinating care with other practitioners, like an occupational therapist (OT).

Tip:  Have your physicians track time spent counseling on a sheet that lists issues that would be typically discussed in a low vision examination. This can be filled out as they go along through the examination by ticking the areas discussed and noting the time spent in minutes.  

Due to the complexity of the patient’s problem and the time involved, LV evaluations may justify a high-level code, according to Maggie Mac, CPC, CEMC, AAPC Fellow CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “You’ll need to document exactly how your time was spent in the patient’s record,” she says. “Make sure you support medical necessity. The record will need to address the patient’s visual impairment, functional disabilities, and their ability to benefit from vision rehab.”

For non-Medicare LV Patients, Consider Consult Codes

Many of your low vision patients are likely to be covered under Medicare, but visual impairment occurs in people of all ages. If you’re billing a private payer, and the service meets the definition of a request for consultative advice and/or opinion, you may be able to justify billing the consultation codes. Medicare doesn’t accept these codes, but some private payers do, and those codes usually reimburse at a higher rate than either eye or E/M codes.

Office visit consultation codes (99241-99245) must be based on a healthcare professional’s written or verbal request for an opinion and advice on the LV diagnosis and treatment. To properly document the consultation, you’d review any medical records the patient provides from the requesting providers, conduct the examination, and provide your impression and recommendations for treatment. You must also respond to the requesting provider and send a follow-up letter or report.

Warning: It is not likely that a request for a consultation would occur very often, as the visit to the ophthalmologist is most likely a referral for treatment and not a request for an opinion and advice.

Don’t Miss These ICD-10 Codes for Low Vision

First code the disease, then use the impairment code as a secondary code, Mac says. “If you look up the impairment codes in ICD-10, you’ll find a note instructing you to code first any underlying cause of the blindness. For example, if the patient presents with 20/200 vision due to proliferative diabetic retinopathy, you’d code E11.355- as the primary code, and H54.8 as the secondary code.

Good news: Coding visual impairments is one area when ICD-10 will actually save you time. In ICD-10, there are 17 codes for blindness and low vision, compared to ICD-9, which had 45.