Optometry Coding & Billing Alert

Question: I visited a patient who was in a nursing home. Should I use an eye exam code or a nursing facility service E/M code?

Hawaii Subscriber

Answer: You're on the right track that you can report only one of these codes, not both. The Correct Coding Initiative (CCI) bundles eye exam codes 92002-92014 (Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program ...) into 99307-99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient ...), 99324-99328 (Domiciliary or rest home visit for the evaluation and management of a new patient ...) and 99334-99337 (Domiciliary or rest home visit for the evaluation and management of an established patient ...). These bundles have a modifier indicator of "0," meaning you cannot report the bundled codes separately under any circumstances.

Best bet: Experts recommend coding an intermediate eye exam (92002 for new patients or 92012 for established patients) for routine visits because you'll need less documentation to substantiate this code. To report a subsequent nursing facility care code (99307-99310), you would need to meet CPT's requirement to review the medical record and the results of diagnostic studies, as well as changes in the patient's status.

If, however, you are seeing the patient for a medical problem (such as glaucoma) or are evaluating a more far-reaching systemic disease process--and can meet the documentation requirements for history, examination and medical decision-making--you may report an E/M code.

Select the E/M code based on the type of facility. The nursing-facility codes (99307-99310) are for services provided within a facility in which 24-hour medical services are available. Domiciliary, rest home and custodial-care codes (99324-99337) are for nursing homes that provide room and board, as well as personal assistance. You should use domiciliary codes only when the nursing facility does not provide medical assistance to its residents.