Wiki Billing complete exams

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rbassett

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I have been told that billing for a complete exam (92004/92014) more than once per year would be “upcoding” and could potentially be cause for an audit if used. One of the providers I code for is a retina surgeon. I review his notes for each exam and he is very thorough and almost always hits the criteria for a complete exam on every visit for a patient due to the high risk nature of the diseases his patients normally have. Am I okay to be billing 92014 on say a second or third visit, or would that be cause for alarm for payers? They want me to instead bill 92012 for every visit the rest of the year after a 92004/92014 is billed for a patient which I think is actually “undercoding.” At the very least I should be able to bill for a 99213 or 99214 if the criteria is met for those. Please let me know what you think.
 
I bill for a retina specialist as well and regularly bill the 92014 when documentation warrants it. I think it is appropriate to bill according to what is documented. Hope that helps.
 
rbassett said:
I have been told that billing for a complete exam (92004/92014) more than once per year would be “upcoding” and could potentially be cause for an audit if used. One of the providers I code for is a retina surgeon. I review his notes for each exam and he is very thorough and almost always hits the criteria for a complete exam on every visit for a patient due to the high risk nature of the diseases his patients normally have. Am I okay to be billing 92014 on say a second or third visit, or would that be cause for alarm for payers? They want me to instead bill 92012 for every visit the rest of the year after a 92004/92014 is billed for a patient which I think is actually “undercoding.” At the very least I should be able to bill for a 99213 or 99214 if the criteria is met for those. Please let me know what you think.
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Depends on the patient's insurance: Kentucky Medicaid and EyeMed (to name a few) will only allow one complete exam per calendar year. Other carriers vary as to what they will allow.

David E. Keown, CPC, OCS
 
I just found on Medicare's mutually exclusive edits spreadsheet that 92014 is allowed once per 3 day period!
I also think some of the confusion comes from the fact that usually you can bill one 92014 with a VISION dx per year to vision plans.
 
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