Optometry Coding & Billing Alert

Tip: Check modifier indicators for ability to report codes separately.

If your practice provides visual function screenings, you need to pay attention to the latest set of Correct Coding Initiative edits.

“Overall, it’s a bit of a yawn this time, which is probably good. There are 4,322 new edit pairs, bringing the total active list to 1,314,537 active pairs,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Nearly 80 percent of the new edit pairs were defined by the policy statement “CPT® Manual or CMS manual coding instructions.”

Of interest to optometry coders is a new group of edits in CCI 20.1 that establish that the codes used to describe eye exams:

• 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient)
• 92004 (...comprehensive, new patient, 1 or more visits) 
• 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient)
• 92014 (... comprehensive, established patient, 1 or more visits)

now include 99172 (Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision [may include all or some screening of the determination(s) for contrast sensitivity, vision under glare]). 

CCI has marked these edits with modifier indicator “0,” which means that 99172 cannot be reported with 92002-92014 under any circumstances. If they are reported together, only the column 1 codes (92002-92014) will be reimbursed.

“I’m not surprised at this edit at all,” Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “The eye exam usually includes all the components of the 99172 service, so it is a likely bundling edit.”

CPT® code 99172 was created for occupational medicine practitioners who needed a code for screening of pilots and other professionals. It is not frequently used by optometrists, say experts.

However, there may be times where an optometrist would use the 99172 code “for patients who need clearance for their jobs, recertifications or licensure to operate certain vehicles and machinery,” notes Mac. “It would probably be mandated by the employer or licensing/recertification board and covered only by private payers or employers or could even be an out-of-pocket expense for the patient.”