Optometry Coding & Billing Alert

Facing the “two visual fields for a bleph patient” dilemma? Read on for our expert advice.

Visual field testing (CPT® codes 92081-92083, Visual field examination…) is a big component of many optometric practices, used on patients from glaucoma suspects to blepharoplasty candidates. Whether you’re a VF coding newbie or a seasoned expert, the answers to these questions can help you get all of your deserved reimbursement.

Question: How many isopters do I need to plot on the Goldman perimeter to be able to report CPT® code 92083?

Answer: A common mistake ophthalmologists make is billing 92082 when they could legitimately bill 92083.

The key to choosing the correct VF code is in the code descriptors themselves. For example, if the optometrist plots only two isopters on the Goldmann perimeter, CPT® would call that “intermediate,” based on its description of 92082. If you plotted three isopters, however, that would be an “extended” examination that would qualify for 92083.

Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspect neurological damage. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma.

Glaucoma causes a loss of vision like a light bulb slowly becoming dimmer and dimmer, while trauma often causes sudden, complete loss of central or peripheral vision. In screening fields, you are testing whether the retina is “on or off,” while in threshold testing you are testing “how dim a light you can perceive.”

Bottom line: Document medical necessity for the level of visual field testing that is ordered, say experts.

Question: Are the visual fields codes unilateral or bilateral?

Answer: When deciding whether to bill for services “unilaterally,” per eye, or “bilaterally,” for both eyes, the first thing to do is read the code description in CPT®. All of the visual field testing codes have in their description the phrase “unilateral or bilateral”:

• 92081 — Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent)
• 92082 — ... intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)
• 92083 — ... extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2.

This means that the payment that has been established for the service is for one or two eyes, and you should only submit a bill for one service — even if the optometrist performed it on both eyes.

Question: How should we code for a VF ordered by a doctor outside the practice, which will be sent back to the ordering doctor for interpretation?

Answer: Report only the technical component of the visual field test. Append modifier TC (Technical component) to the code to report your work. The ordering ophthalmologist should report his work by appending modifier 26 (Professional component) to the code.

Question: What diagnosis codes would we use for a VF test to rule out the possibility of glaucoma?

Answer: Because the results of the VFs were negative — they did not confirm glaucoma or any condition — you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes.

Example 1: A patient presents with high intraocular pressure, a sign of glaucoma, and the optometrist decides to perform a visual field (VF) examination. The results of the visual field were normal, and the doctor ruled out the possibility of glaucoma.

In this case, the appropriate ICD-10 diagnosis code is one of the following, depending on which eye is affected:

• H40.011 – Borderline glaucoma; open angle with borderline findings, low risk, right eye
• H40.012 – … left eye
• H40.013 – … bilateral
• H40.019 – … unspecified eye.

Some payers require a code from the H40.001-H40.009 (Preglaucoma, unspecified) series when the diagnostic testing does not confirm glaucoma. Your best bet is to check with your local carrier to determine if billing guidelines exist.

Example 2: The optometrist performs visual fields for a patient who presents with high intraocular pressure, open angle, and the VFs confirm the presence of small scotomas in the areas of the VF related to glaucoma.

If a patient presents with signs and symptoms of glaucoma, and a VF confirms the condition, you should report the code for the confirmed diagnosis. The VF code should be linked to the appropriate glaucoma ICD-10 code – in this case, one of the following:

• H40.10X0  – Unspecified open-angle glaucoma, stage unspecified
• H40.10X1  – … mild stage
• H40.10X2  – …moderate stage
• H40.10X3  – …severe stage
• H40.10X4  – …indeterminate stage.

Question: How should we report two visual fields performed prior to a blepharoplasty operation?

Answer: To determine the extent to which a blepharoplasty candidate’s droopy eyelids interfered with her vision, the optometrist performs two bilateral visual field tests on the same day (Humphrey full-field 120 point). He performs the first field test normally, and the second after taping the patient’s eyelids. The diagnosis is dermatochalasis (H02.83-).

Most Medicare carriers want you to report just one code for visual field (VF) tests, even if an optometrist needs to perform the test twice — once with lids untaped and once with lids taped — to confirm that the dermatochalasis is interfering with vision. Ophthalmologists often perform these tests prior to performing blepharoplasty procedures to correct the eyelid drooping.

For those carriers, report one unit of the appropriate 92081-92083 code. Since the definition states “unilateral or bilateral,” report just one unit even when the ophthalmologist examines both eyes.

Some carriers will reimburse you for both tests because they mandate two VF tests to support the diagnosis and medical necessity for the surgery. If this is the case, you should append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to the second test and report the visual field code twice — the first time with no modifier and the second time with modifier 76. You can add comments in Block 19 of the claim form (or the electronic equivalent) to indicate “taped and untaped.”

Try this: One way to reduce the amount of time spent in visual field testing is to create a custom visual field that uses lots of points superiorly and only a few spots below the line of sight.