Optometry Coding & Billing Alert

Question: How should we handle it when a patient who has come in for a regular eye exam insists on coming back at a more convenient time to have his eyes dilated for the glaucoma check? Should I code this as one visit after the patient comes back, or are they considered two separate visits?


Maryland Subscriber

Answer: If the patient returning for a dilated follow-up (also known as a dilated fundus examination or DFE) is a Medicare patient, bill your services - including both days' work - as one unit of a comprehensive ophthalmological examination (92004 or 92014). Medicare has stated that a comprehensive ophthalmological examination (92004 or 92014) may take place on more than one day (note the phrase "one or more visits" in the CPT descriptions of those codes).
 
For a non-Medicare patient, bill separately for the office visits rendered on both days. For the medical record for each visit, record the chief complaint, an initial or interval history, examination of findings, and an impression and plan for treatment. You will most likely arrive at billing two intermediate or problem-focused E/M visits (such as 99202 for a new patient or 99213 for an established patient) instead of one comprehensive eye exam code.