Optometry Coding & Billing Alert

Use the 99200 codes for patients with specific problems -- but make sure your documentation backs them up

Optometrists have a unique benefit in the CPT manual, but that benefit can sometimes become a problem: Optometry and ophthalmology are the only specialties that have their own set of codes that can be substituted for the evaluation and management codes -- the problem is knowing when to use which set of codes.
 
Both sets of codes -- the E/M codes (99201-99215, Office or other outpatient visit -) and the general ophthalmological services codes (92002-92014, Ophthalmological services: medical examination and evaluation -) -- describe office visits, says Melanie Beus, OCS, coder for Country Hills Eye Center in Ogden, Utah. So how should you decide which to report?

Switch to E/M Codes for Complicated Exams

Experts warn: Don't choose based on amount of reimbursement. The general rule for CPT codes is to pick the code that most clearly describes the service the optometrist renders. If you are strictly evaluating the function of the eye, report an eye code. If, however, you are evaluating the eye as related to a systemic disease process, report the appropriate E/M code, says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.
 
-If an eye exam gets complicated and has multiple diagnoses or health problems, I would switch over to an E/M code because it addresses the medical complexity of the patient, while the 92000 codes do not,- says David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.
 
Example 1: A new patient presents complaining of blurred vision. You perform a comprehensive examination, including checking her visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure. Since this is strictly an examination of the eyes- function, use 92004.
 
In this scenario, -the proper treatment may be to continue monitoring the condition without -treating- at this point,- Gibson says.
 
Example 2: A patient with chronic blepharitis comes in due to a recent foreign-body sensation. During the case history, the patient mentions a recurring headache. The patient had an unremarkable comprehensive exam four months ago, and you don't think it's necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye. Refraction indicates a significant increase in hyperopia, which may explain the headache.
 
You can report an E/M code -- as long as you meet the higher standard of documentation for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined in the E/M codes that are not specified in the eye codes. Many carriers look for an E/M code if there is a medical diagnosis, Beus says.
 
Good advice: Keep high documentation standards. -We try and make sure all of our office exams meet the qualifications for an E/M code,- because they-re the most strict, Beus says.

Check Carriers for -Comprehensive- Definition

Your CPT manual has definitions of -intermediate ophthalmological services- and -comprehensive ophthalmological services.- Be careful, however: Individual carriers have refined those definitions even further.
 
If you don't meet your carrier's definition of -intermediate- or -comprehensive- eye exams, you should report an E/M service code instead of an eye code. The intermediate level requires a new problem -- a new condition, a new complaint, a new management issue, experts say. -A new complaint could be blurry vision that wasn't noticed until recently,- Gibson says.
 
Smart step: Check your carrier's local coverage policies for specific guidelines. For example, part B carrier TrailBlazer (Delaware, Maryland, Texas, Virginia and Washington, D.C.) includes 13 elements in its definition of an ophthalmologic examination:
 
- Visual acuity
 
- Gross visual fields
 
- Eyelids and adnexa
 
- Conjunctival inspection
 
- Ocular mobility
 
- Pupils/iris
 
- Cornea
 
- Anterior chamber
 
- Lens
 
- Intraocular pressure
 
- Retina (vitreous, macula, periphery, and vessels)
 
- Optic disc
 
- Mental status.

To qualify to report a comprehensive eye code (92004 or 92014) for a TrailBlazer patient, an optometrist must examine and document nine or more of these elements -- always including gross (or confrontation) visual fields, eyelids and adnexa, and ocular mobility. Only the gross visual field tests are included in the comprehensive exams, Gibson says -- the more extensive tests reported with 92081-92083 are not included.
 
A comprehensive exam also -always includes a fundus examination with the pupils dilated, unless medically contraindicated,- TrailBlazer says. An intermediate ophthalmological exam (92002 or 92012) -includes the evaluation of eight or fewer of the specified elements.-
 
Hidden trap: Not all local polices are the same, however. For example, Part B carriers CIGNA (Idaho, North Carolina and Tennessee) and Palmetto GBA (Ohio, South Carolina and West Virginia) both include only 10 items in their list of exam elements (visual acuity, conjunctival inspection and mental status are not there). The optometrist must examine and document eight or more of those elements, as well as a dilated fundus exam, to bill a comprehensive exam for a Cigna or Palmetto patient.
 
Trailblazer also specifies that gross visual fields, eyelids and adnexa, and ocular mobility tests are required for a comprehensive-level exam; CIGNA and Palmetto do not specify that.

Don't Rely on 1 Type of Code

-No other specialty has a code for their profession like we do with the 920xx codes, so we need to use them,- Gibson says. But using one type of code exclusively could draw attention, he says. -The major companies look at the codes as a percentage of what you bill as opposed to other optometrists. You are more likely to be audited for filing exclusively 920xx codes or exclusively 992xx codes, so you need to use them all.-
 
Codes 92002-92014 are -much easier to defend in an audit, but for specific problems, the E/M codes are better,- he says.