Advanced Search

Ophthalmology and Optometry Coding Alert

Stop Denials for Visual Fields Performed for Stop Denials for Visual Fields Performed for

Published on Sun Jun 01, 2003

Sure, you can look up each individual carriers list of covered diagnosis codes for visual field examinations and pick the closest match to your physicians documentation, but what should really drive your coding is that visual fields are diagnostic tests when performed to diagnose glaucoma.

When there isnt a national policy issued by the Centers for Medicare & Medicaid Services (CMS) listing covered diagnosis codes for a procedure, coders are constantly trying to figure out which diagnosis codes will be acceptable for a given procedure. Before you start researching and re-researching carriers policies, it is a good idea to stick with the basics, otherwise you could find yourself choosing a diagnosis code just because it is covered, a.k.a. committing billing fraud.

Put the Diagnostic Test Basics to Work

"Visual field exams are used to test the patients peripheral vision" when performing a glaucoma exam for a symptomatic patient, says Nicola DuHamel, administrator for the Bascom Palmer Eye Institute of the Palm Beaches in Florida. "They are billable approximately every six months depending on the type of insurance," and they require interpretation and report, she says.

Use the standard requirements for coding diagnostic tests issued by CMS in September 2001 to guide your choice of diagnosis codes for visual field (VF) examination codes 92081 (Visual field examination, unilateral or bilateral, with interpretation and report; limited examination [e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent), 92082 ( intermediate examination [e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33]) and 92083 ( extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

How you assign diagnosis codes for diagnostic tests really depends on whether you submit the claim for the ordered test before or after the physician has received and interpreted the test results.

If the physician who ordered the test has not received the results, the patients diagnosis code should reflect the signs and symptoms the patient presented with. If  the physician has the results of the test before submitting the claim and those results are negative, you should still code the signs and symptoms that prompted the physician to order the test. However, if the same physician who orders a test receives and interprets the results as positive before the claim has been sent to the carrier, such as when a comparative or test is performed, report the diagnosis codes for the positively identified condition, for example, glaucoma.

According to CMS Program Memorandum AB-01- 144, Medicare has taken the following stance on assigning diagnosis codes for diagnostic services:

If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis.

If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the signs or symptoms that prompted the treating physician to order the study. (That does not ensure, however, that you will receive payment the first time you submit your claim. You may end up proving the medical necessity of performing the service by providing documentation after receiving a denial, says Raequell Duran, president or Practice Solutions in Santa Barbara, Calif.)

If the results of the diagnostic test are normal or nondiagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) or symptom(s) that prompted the study. Diagnoses labeled as uncertain are considered by the ICD-9-CM coding guidelines as unconfirmed and should not be reported.

This contrasts with the language within the evaluation and management code documentation guidelines, which state, "For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a possible, probable or rule out (R/O) diagnosis," Duran says.

"ICD-9 does not provide us with rule out diagnosis codes," she says. "There is a code in ICD-9 that is defined as Ruled-out condition, V71.9, but the way claim systems work, if you were to report a definitive condition as diagnosis number one on your claim form, and V71.9 as your number-two diagnosis, the computer system may not look to the second diagnosis when your claim is processed. It would appear that you were reporting the (suspected) condition as the reason or result of the testing service and upon review could appear as a fraudulent claim.

Apply the Basics to Visual Fields

Although many physicians feel the need to provide a definitive diagnosis when submitting a claim, diagnosis coding is one of the few coding is one of the few activities when a complaint will actually get you somewhere. There are many circumstances in which the symptom the patient  presented with is the only thing they can find suspected glaucoma is one of those circumstances.

"Signs and symptoms [of glaucoma] are decreased vision, pain, redness in the eye, increased intraocular pressure, iritis (which is an inflammation of the eye), and also rubeosis, which is blood vessels on the iris," DuHamel says. "If any of these are the reasons for the visit, again they must be documented in the record under chief complaint."

Lets say a patient is referred for the reason of high intraocular pressure, a symptom of glaucoma, and the ophthalmologist decides to perform a visual field examination. The results of the visual field are normal, and the ophthalmologist rules out the possibility of glaucoma. Because the results of the visual fields are negative (they did not confirm glaucoma or any condition), the ophthalmologist should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable visual field code, and include any additional observations from the visual fields in his office notes. In  this case, the appropriate diagnosis code is glaucoma suspect, open angle, borderline IOP or ONH cupping.

On the other hand, if a patient presents with signs and symptoms of glaucoma and a visual field examination confirms the condition, the code for the confirmed diagnosis should be reported. For example, if an ophthalmologist performs visual fields for a patient who presents with high intraocular with high intraocular pressure and the visual fields confirm the presence of small scotomas, the visual field examination CPT code should be linked  to the appropriate glaucoma diagnosis code, in this case 365.10 (Open-angle glaucoma, unspecified).

Report One Test Code for Both Eyes

The visual field examination codes are considered inherently bilateral diagnostic tests, Duran says. Therefore, the VF codes already account for the test when it is performed in both eyes. Suppose a patient is referred for a glaucoma consultation, and this is the chief complaint motivating the visit. The ophthalmologist performs an extended-level visual field in each eye; code 92083 should be reported only once.

But in the Medicare program, there is a list of ophthalmology- related diagnostic tests that are considered inherently unilateral, are billable for each side, and are approved at 100 percent of the fee schedule when there is medical necessity for performing the test on each eye.

These unilateral diagnostic services include:

76511 Ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification

76512 contact B-scan (with or without simultaneous A-scan)

76513 anterior segment ultrasound, immersion (water bath) B-scan or high-resolution biomicroscopy

76519 Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation

76529 Ophthalmic ultrasonic foreign body localization

92135 Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral

92225 Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial

92226 subsequent

92230 Fluorescein angioscopy with interpretation and report

92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report

92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report.

Other Articles in this issue of

Ophthalmology and Optometry Coding Alert

View All