Pediatric Coding Alert

FAQs:

Clearly See the Answers to These Vision Screening FAQs

Published on Tue May 07, 2024

Also: find guidance on billing vision screenings with well-child visits.

When it comes to vision screenings, questions about coding are common. Knowing which codes to use and when is a source of confusion for a lot of pediatric coders. To help you out, we’ve selected four of the most frequently asked questions (FAQs) about this topic.

If you think your understanding of vision screening coding could benefit from some clarity, this one’s for you.

Question 1: What are the differences among visual screening codes 99172, 99173, and 99174/99177?

Answer: CPT^® code 99172 (Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination[s] for contrast sensitivity, vision under glare)) is a code for vision screenings performed in occupational medicine on adults in professions that require excellent sight or where there are vision safety standards. So, it is unlikely you would use this in a pediatric context.

CPT^® code 99173 (Screening test of visual acuity, quantitative, bilateral), on the other hand, is very typically used for pediatric vision screenings. Per the CPT^® instructions for the code, providers usually perform this screen using a Snellen chart, the familiar eye chart that features letters in rows of descending size.

CPT^® codes 99174 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report) and 99177 (…with on-site analysis) are also used in pediatrics, especially with preverbal, nonverbal, or noncooperative patients. The service involves using a device that takes images of the child’s eye to screen for any abnormal conditions. You would report 99174 if your office transmits the images from the test to an outside interpreter and 99177 if you perform the interpretation in-house. “Workflow and vendor variations can have an effect on which of these codes applies to the services that your practice performs.” cautions Jan Blanchard, CPC, CPEDC, CPMA of Vermont-based Physician’s Computer Company. “Verify with your vendor exactly how you can discern where the interpretation is taking place for each given instance of these tests. In addition to crucial coding accuracy, the 2024 RVU value of 99173 is less than 64% of 99177.”

Question 2: Can I separately bill a vision screening with a physical?

Yes, in some cases. Per CPT^® instructions for the screening test, “other identifiable services unrelated to this screening test provided at the same time may be reported separately (eg, preventive medicine services). That would include annual well-visit services reported with 99381-99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient...) /99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual... established patient)) for the physical. That’s because many of the services associated with a preventive evaluation and management (E/M) service can be billed separately.

Also: You can bill vision screens such as 99173 alongside developmental screens such as 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument) and behavioral screens such as 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/ hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) depending on the patient’s age and development.

In fact, “all screening and testing services can be billed with any E/M service, whether it be a preventive or a sick visit E/M, under appropriate circumstances,” according to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

And should the patient be vaccinated during the service, you can also bill for the vaccine along with the vaccine administration using 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …).

Question 3: What should I do if I report the vision screening and physical separately but the payer denies the claim?

As mentioned earlier, CPT^® guidelines allow you to bill these services separately. However, some payers will still say the services are bundled and subsequently deny the claim. This is an example of why it’s a good idea to fully understand the payer contract.

The best thing to do if you get a denial like this is to carefully check the contract for any agreements that override the CPT^® guidelines. If there isn’t language about bundling, you can appeal the denial. CPT^® is very clear in saying that screenings are distinct services, so if carriers are bundling them without a previous arrangement, they’re in violation of your contract.

Remember: To help ensure the success of your appeal, use concise language and submit any relevant documentation. However, if the payer has clearly outlined that the services are bundled in the contract, be sure to make a note of that to avoid this kind of denial in future.

Question 4: Can I use modifier 52 or 53 to report a vision screening the pediatrician can’t complete due to the child not recognizing some letters or the child not being able to sit still long enough?

Unfortunately, appending modifier 52 (Reduced services) or 53 (Discontinued procedure) to 99173 or 92551 (Screening test, pure tone, air only), for example, would be incorrect under these circumstances.

That’s because, per appendix A of the CPT^® manual, modifier 52 is used when “a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional.” In this case, the service was not really terminated by pediatrician choice; instead, the patient’s circumstances made completion of the service impossible.

Also, per appendix A, modifier 53 would not be correct as it is used to “terminate a surgical or diagnostic procedure.” Neither 99173 or 92551 fits those criteria.

Under these circumstances, your only real option would be to not bill for the service.