Ophthalmology and Optometry Coding Alert

Question: We do not dilate our VSP patients- eyes but still bill 92004/92014 because VSP doesn't require dilation. I am wondering if we are under possible auditing risk when we bill these patients with the level-four CPT even though we are not "checking off" the periphery as "normal" for the posterior segment. For example, a VSP patient comes in with level-four history and level-four exam, and the decision-making is level-two. The "Exam" elements include: External (pupils, CF, EOM, adnexae), Slit Lamp (eyelids, sclera/conj, cornea, AC, iris, lens), Posterior (vitreous, disc/optic nerve, macula,vessels). Am I allowed to code this at level-four?

California Subscriber

Answer: Often there are local coverage determinations (LCDs) that will provide guidance on the required elements of the eye codes. But there doesn't appear to be a specific policy regarding elements required for using the eye codes for the California Medicare carrier.

Caveat: Third-party payers, such as VSP, may have specific policies concerning what services and diagnostic tests your ophthalmologist must perform for you to code at the intermediate and comprehensive levels of assignment.

CPT's take: CPT guidelines state: "The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examination, gross visual fields, and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs."

What it means: Therefore, taking the CPT guidelines into consideration, the required elements for a comprehensive code assignment (92004 or 92014) are history, general observation, external exam, ophthalmoscopic exam, gross visual fields (GVF) and sensorimotor. From your example, your ophthalmologist appears to have completed all of these elements except the GVF.

Important: Note that the levels of history, exam and medical decision-making do not apply to the eye codes. CPT requires the physician to render specific services and, in some cases where a payer has a policy, the ophthalmologist must perform a specific number of elements. Additionally, some payers may require a dilated exam, although it is not a requirement per CPT guidelines.

Best bet: Contact each of your payers to determine if they have specific policies for performance and assignment of the eye codes at the intermediate and comprehensive levels.