Ophthalmology and Optometry Coding Alert

Question: We’re confused about what codes we would report for an office visit. Can we bill 92002 and 99204 together for the same patient on the same date of service? The same ophthalmologist provided both services.

Virginia Subscriber

Answer: No. You cannot bill these two codes together because they indicate the same type of service — a new patient visit. Ophthalmology is the only specialty that has its own options to report office encounters, and for each encounter, you must choose whether to opt for an evaluation and management (E/M) code or an eye code.

From the E/M code range for new patient visits, you could choose 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter) from the 99202-99205 code range if the documentation supports the full service.

On the other hand, your ophthalmology options are: 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) and 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits).

Choosing between the E/M and eye examination codes can be a little more challenging, but generally if your ophthalmologist just evaluates the eyes’ function or performs a routine exam, you would typically choose an ophthalmological code: 92002 or 92004.

For more complicated cases, like with patients who present with chronic conditions, new problems, and injuries, either an eye exam code or E/M code may apply.

Remember, if you do choose an E/M code over an ophthalmology code, the documentation must support the code selection based on the new 2021 guidance from the AMA. Code based on either physician time spent or the medical decision making component.

Note: Different payers may have different rules about policies regarding the use of eye codes 92002-92014. Check with your payer if you are unsure.