Optometry Coding & Billing Alert

Optometry coders have been both blessed and burdened with having two sets of CPT codes available for coding patient office visits: E/M codes and eye codes.

Having the option to use the ophthalmic exam codes (92002-92014) or codes from the evaluation and management series (99xxx) for patient exams doesn't change how you should go about assigning the appropriate office visit, though. "Our goal is always to choose the code that best describes the service performed," says Linda Abel, CPC, assistant administrator with Hauser-Ross Eye Institute in Sycamore, Ill.

For these unique eye codes, 92002-92014, to feel like a blessing, you first need to understand what these codes encompass and when they should be reported. "The basic difference between the two sets of codes is that the eye codes are used for evaluating the function of the eye, whereas the E/M codes are generally used when the [optometrist] is evaluating a more systemic disease process," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C.

She cites the example of a patient presenting with some symptoms of glaucoma but also with headaches that need to be evaluated in the context of the patient's current condition. This additional evaluation, with the appropriate documentation, constitutes an E/M service.

"But if a patient comes in with just the complaint 'I can't see well,'then the [optometrist] will simply be evaluating the function of the eye, justifying the use of an eye code," Callaway says.

There are times when it is hard to tell whether an eye code or an E/M code is appropriate.

For example, a patient comes in for her regular checkup and says, "By the way, I have these other problems or concerns." "This could really go either way and require eye or E/M codes," Callaway says. "Then it is your responsibility to follow the basic CPT rules that advise you to pick the code that most clearly describes the services you are rendering."

The eye codes, like the E/M codes, are divided into new patient (92002 and 92004) and established patient (92012 and 92014) classifications, which are further broken down by their level of service.

Unlike the E/M codes, the eye codes have only two levels of service, intermediate and comprehensive, making it easier to determine the level of service that your optometrist has provided to a patient.

The question still looms: Why would an optometrist or coder opt to use the eye codes instead of the E/M codes, when either set is applicable? For many coders, the answer lies in the depths of documentation.

You tend to need a more extensive history, and more variations have to be considered in medical decision-making when documenting an E/M service rather than an eye code, Callaway says.

While the eye codes don't have national documentation requirements, the majority of local medical review policies provide a list of requirements for the eye codes.

Noridian Iowa's Medicare Part B policy provides the following 10 examination requirements for an exam reportable using the eye codes: