Ophthalmology and Optometry Coding Alert

When billing followup visits for patients with chronic conditions, 92012 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) is usually more appropriate than 92014 (... comprehensive, established patient, one or more visits). Either 92012 or 92014 is often better than the evaluation and management (E/M) established patient codes (99212-99215) because the eye code documentation requirements are less stringent. Furthermore, if you perform the required components of the service per your Medicare carrier, you may have better reimbursement with the eye codes.

The best way to decide whether to bill 92012 or 92014 is to look at documentation guidelines in CPT or in the local medical review policy (LMRP) for your Medicare carrier. However, the two sets of documentation guidelines may not agree; if the patient is covered by Medicare, you must follow the guidelines of your Medicare carrier.

CPT Guidelines

Some coders use the comprehensive exam code (92014) instead of 92012, because under CPT the documentation guidelines for 92014 do not require a new or existing condition complicated with a new diagnostic or management problem.

However, 92014 always includes initiation of diagnostic and treatment programs, according to the preface to the ophthalmology codes in CPT. Often, a followup visit involves no initiation of a diagnostic and treatment program. If there is no such initiation, use intermediate eye CPT Code 92012.

Check LMRP Requirements

Many Medicare carriers do not follow CPTs guidelines in all respects. Again, check with your local carrier to determine the specific documentation requirements for 92012 and 92014.

Most carriers have their LMRP for the eye codes listed on the Web site (www.lmrp.net). If your carrier does not have a policy, contact the provider relations department to ensure there is no LMRP in your carrier area.

Carrier Example: Idahos 92014-92012 Policy

All Medicare carriers require that certain services be performed in order to justify the eye codes. In Idaho, for example, according to policy ID 97-006 (general ophthalmological services), eight of the 11 following services must be performed in order to qualify for a comprehensive exam (92014 in an established patient):

Test visual acuity (does not include refraction)
Confrontation visual fields
Eyelids and adnexa
Ocular motility
Pupils/iris
Cornea (requires slit lamp)
Conjunctiva (requires slit lamp)
Anterior chamber (requires slit lamp)
Lens (requires slit lamp)
Intraocular pressure
Ophthalmoscopic exam

In addition, according to the policy, a comprehensive examination always includes a fundus examination with the pupils dilated.

Use the eye codes when the level of service includes several optometric/ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry and motor evaluation that are integrated with and cannot be separated from the diagnostic evaluation, according to the policy. (Do not itemize any of these individual services.) For an intermediate exam (92012), you need only seven (or fewer) of the above elements.

Services that require minimal optometric/ophthalmologic examination techniques are included in the evaluation and management codes (99201-99499), the policy states.

The intermediate exam is for a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, according to CPT.

For 92014, the ophthalmologist must make a general evaluation of the complete visual system. History, general medical observation, external and ophthalmoscopic examination, gross confrontation visual fields and basic sensorimotor examination, and initiation of diagnostic and treatment programs are always included. Biomicroscopy, dilated ophthalmoscopy and tonometry are included as indicated.

The phrase initiation of diagnostic and treatment program confuses many coders. It could mean prescription of medication, arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services. For example, a glaucoma check at three months in which eight or more of the items in the policy need to be performed and a visual field is ordered and performed could qualify for a 92014.

The Idaho policy is used here as an example only. Be sure to check your carriers Web site for the LMRP for the eye codes, or call the carrier to get a copy to determine the documentation and reasonable and necessary requirements in your Medicare area.