Wiki Comprehensive Eye Exam

[kathy a]

If the Physician performs all of the Elements of the eye exam , but doesn't put in anything about Neurologic or Psychiatric,does that void the Comprehensive Eye Exam ? Would an E & M code need to be billed out then ? I am still confused over this and don't know if my Physician needs to know this. Thank-you.

Kathy Albert,CPC

 

[kathy a]

Eye Exams

I did go to the AAO Website. There was an explanation of the Comprehensive Eye Exam Codes and E & M Codes.
For the Comprehensive Eye Exam all 12 elements must be documented. In addition you must document initiation of a diagnostic and treatment program. If less than 12 it is considered a Intermediate Exam.
An Intermediate Exam consists of less than 12 elements.
For E & M codes, you have five levels of exam. To bill for the Comprehensive Exam all 12 elements must be documented, as well as a note reflecting the patient's orientation, mood and effect.

Kathy Albert,CPC

 

[Cheezum51]

Yes, the physician does have to document the neuro and psych as part of the exam even though those area may be covered in the review of systems as well.

Tom Cheezum, O.D., CPC, COPC