Ophthalmology and Optometry Coding Alert

Question: A patient is in for a routine exam and has no complaints. The ophthalmologist finds intraocular pressures of 30 mm Hg in both eyes along with suspicious cupping. The physician performs gonioscopy and visual field (VF) testing but does not find any evidence of glaucoma.

What codes are reported for the procedures and diagnosis? Which diagnoses will prove medical necessity for the gonioscopy, and where can I find this information?

AAPC Forum Participant

Answer: In this case, the additional testing was medically necessary due to the abnormal exam findings.

Testing: Report 92020 (Gonioscopy (separate procedure)) for the gonioscopy. Then based on the extent of examination the physician performed and documented, select the most appropriate visual field testing code:

• 92081 (Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent))
• 92082 (… intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33))
• 92083 (… extended examination (eg, 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))

Diagnosis: Link both CPT^® codes to ICD-10-CM code H40.013 (Open angle with borderline findings, low risk, bilateral).

Supporting dx: Indications for gonioscopy may include, but are not limited to, glaucoma, ocular trauma, eye infection, hypotony, occlusive disorders, diabetic retinopathy, rubeosis, aphakia, intraocular foreign body, and a subluxated or dislocated lens

Other diagnoses that many insurers accept to prove medical necessity for gonioscopy include:

• H40.00- (Preglaucoma, unspecified)
• C69.4- (Malignant neoplasm of ciliary body)
• C79.31 (Secondary malignant neoplasm of brain)
• D31.4- (Benign neoplasm of ciliary body)
• D33.3 (Benign neoplasm of cranial nerves)
• H34.1- (Central retinal artery occlusion)
• H34.81- (Central retinal vein occlusion)
• H20.00 (Unspecified acute and subacute iridocyclitis)

Ultimately, the diagnoses that support the gonioscopy’s medical necessity depend on the payer policies; each one you bill may have different rules regarding 92020 reimbursement. Some Medicare administrative contractors (MACs) publish detailed local coverage determinations (LCDs) with an extensive list of the approved indications for gonioscopy. In many cases, you can search for coverage decisions on the insurer’s website.

Remember: Merely linking an appropriate diagnosis code to 92020 isn’t enough to support the medical necessity for the test. Your ophthalmologist must document the diagnosis or clinical signs and symptoms in the patient’s medical record.