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Ophthalmology and Optometry Coding Alert

You Be the Coder:

Is Primary Diagnosis Routine or Medical?

Published on Wed Nov 17, 2004

Question: A patient came in stating that she had no changes in vision - she just wanted her yearly checkup. While the doctor evaluated the patient, he found the beginning stages of cataracts. We billed her supplemental vision insurance for the visit, but now she wants it to go through her medical insurance because the doctor did find something. How should we code this, and who gets the bill?

Washington State Subscriber

Answer: Send the bill for the visit to the routine vision coverage. As for correct coding, you should always code according to why the patient is there, based on her chief complaint and history of present illness. Since this patient came in with no specific complaint, but the ophthalmologist diagnosed a medical problem, report the routine visit as the primary diagnosis and the medical condition as the secondary diagnosis.

Bill the patient's vision insurance with the appropriate E/M code (99201-99215) and link it to ICD-9 code V72.0 (Special investigations and examinations; examination of eyes and vision). As a secondary diagnosis, report the appropriate cataract code (366.xx).

However: If a patient presents with no complaints, but the ophthalmologist finds something that makes it necessary to perform tests in addition to the routine screening, you may be able to bill both the medical and the visual insurance.

Example: A patient is in for a routine exam and has no complaints. The ophthalmologist finds intraocular pressures of 30 mm Hg in both eyes and suspicious cupping. He performs gonioscopy and visual fields but finds no glaucoma.

Since the patient had no complaints, bill the eye exam with the appropriate eye code to the patient's vision insurance.

Bill 9208x (Visual field examination, unilateral or bilateral, with interpretation and report; ...) and 92020 (Gonioscopy [separate procedure]) to the patient's medical insurance.

Link the CPT codes to ICD-9 code 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline findings) - or the appropriate 365.xx code if you found glaucoma.

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