Pediatric Coding Alert

To optimize reimbursement for vision screening, pediatric practices need to understand when to use the new code and when an existing code should be billed.

Before the code was added in CPT Codes 2000 99173 (screening of visual acuity, quantitative, bilateral)pediatricians had no way to bill for vision screens done as part of preventive medicine services. But there is one problem with code 99173: It doesnt have a published RVU yet. That means there is no fee attached by Medicare or Medicaid. Insurance companies will be more likely to reimburse pediatricians for the new vision screening code the more doctors use it.

Screening in a pediatric office setting can be done easily by a primary-care pediatrician, says Harold P. Koller, MD, FAAP, FACS, chair of the American Academy of Pediatrics (AAP) section on ophthalmology and clinical professor of ophthalmology at Thomas Jefferson University in Philadelphia.

Early detection of vision problems is important. We believe that every child should be screened by the age of three, says Koller. The reason is amblyopia: If a child has vision problems, once the cells in the brain realize they dont need to process sight a certain way, they die off. Then, even if the eye problem is fixed, its too late. A clear, focused, single vision needs to be registered by the brain, he says. In addition to vision screening, the red reflex test and frank observance of eye alignment should be done at every well-baby check, adds Koller.

The fact that code 99173 lacks an RVU isnt unusual: The vaccine administration codes (90471 and 90472) are in the same position, but some commercial insurance payers are reimbursing for those codes. Nevertheless, it would make it much easier if there were an RVU. Were working hard to attach a value, he says. The section on ophthalmology at the AAP and the designated committees at the American Academy of Ophthalmology are working with the AMA RUC and HCFA to establish a defined and reimbursable fee. The only reason this code ever made it into CPT is that both societies fought hard for it.

When to Use 99173

Here are some basic vision testing methods that can be used, some of which are to be coded 99173, and some of which have separate codes.

1. Wall chart. This is typically a Snellen chart, although there are also wall charts that are pictures. The easiest way to use a wall chart with children, says Koller, who practices with Huntington County Eye Care Consultants in Meadowbrook, Pa., is to give the child cards, and to ask the child to match what he or she is seeing on the chart with what is on the cards.

Matching is much faster than waiting for the child to tell you what it is, says Koller. For example, give the child three cardsone with A, one with E, and one with O. Point to the A on the chart, and ask the child to pick the card that matches. When pediatricians say it takes a lot of time to do vision screening, that is probably true, but if youre trained to do it by matching, its a lot faster, he says. This way, if you do have a problem getting reimbursed, you havent lost so much time, he says. This is an excellent vision screener, and the costs are minimal. Use 99173 for this chart. In fact, CPT specifically mentions the wall chart as appropriate for this code. From the descriptor in CPT 2000: The screening test used must employ graduated visual acuity stimuli that allow a quantitative estimate of visual acuity (e.g., Snellen chart).

2. Welsh-Allyn. This is actually a refractor, not a screener, says Koller, who is also attending surgeon at Wills Eye Hospital in Philadelphia, and a counselor to the American Academy of Ophthalmology. He does not recommend that the Welsh-Allyn be used for vision screening. The Welsh-Allyn uses an ophthalmoscope, and a patient is asked whether they can see something. A minus lens and a plus lens are used. The test results are not visual acuity, they are the refractive error. You could use a refractive code (92015), but that will definitely not fly if you are a primary-care pediatrician trying to do a vision screening. Koller recommends that primary-care pediatricians who want to use Welsh-Allyn use 99173.

3. Photo screeners. Photo screeners can be expensive, but they dont have to be. Yes, you can get a digital machine for $3,000 that will show whether the red reflex is behind the pupils when the picture is taken. If it isnt, or is only behind one pupil, it means there is an abnormality. But you can also do it manually, with a camera or with a hand-held light. This test can help screen for strabismus or similar problems, but it is not a substitute for vision screening. The code for this is 92285 (external ocular photography with interpretation and report).

These are codes that need to be pursued. The new vision screening code is a legitimate code, like the hearing screening code. Right now, most insurance companies will be reluctant to reimburse for this separately, but only because the code is new. Most insurance companies do reimburse for hearing screening, because those codes have been around for a while. If pediatricians use the new vision screening code consistently, insurance companies are more likely to pay for it.