Optometry Coding & Billing Alert

Published on Wed Oct 20, 2004 PDF

Question: I know that Medicare prefers optometrists to use the 92000 codes rather than the 99200 codes for exams. To report 92004 or 92014, our carrier says we have to have done at least 8 out of 10 elements of a comprehensive physical exam (such as visual fields, ocular mobility, and intraocular pressure). But is there a minimum number of elements we should have done before we report an "intermediate" exam with 92002 or 92012? I know it's 7 or fewer - but would just one qualify us?

Texas Subscriber

Answer: A representative for TrailBlazer, Texas' Medicare Part B carrier, says that there is indeed no minimum amount of elements from their list of testing items that an optometrist must perform to report 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) or 92012 (Ophthalmological services: medical examination and evaluation with initiation or continuation of diagnostic and treatment program; intermediate, established patient).

Many other carriers have similar LCDs that specify performing eight or more elements for 92004 (... comprehensive, new patient, one or more visits) or 92014 (... comprehensive, established patient, one or more visits) but don't specify a number to meet their definition of an intermediate exam. They instead quote CPT's definition of intermediate level of service as "the evaluation of a new or existing condition complicated by a new diagnostic or management problem not necessarily relating to the primary diagnosis."

Example: An optometrist sees an established patient for a scheduled pressure test. Since this does not represent a "new diagnostic or management problem," you should avoid the intermediate eye codes and instead report an E/M code - in this case, 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making).