Wiki E/M vs Eye exam

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KoBee

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hello -

These seem to get kind of confusing for me, wondering if anyone have a good source or a cheat sheet that would help how to choose between the two.

Can any one look at this example and tell me if they would code E/M or Eye exam due to " annual exam"? payer is Aetna


Annual Exam

HPI: xxxxxxx is a 64 yo female c/o's
"My eyes get dry and they will blur. I see halos when I am driving at night.
I have to go close when I reading. Last week, Dr. Tillman said that my prescription
is the same. I get tired of reading when I am looking at the newspaper.
I only use the Lumify for the redness when I am going to a dinner or sometimes.
If I use any mascara or makeup then my eyes get more itchy."

Pt denies flashes, floaters or changes in vision (shadow/curtain).
Denies LASIK, CTL use, eyelid surgery, OTC anti-histamine use.
ROS negative for xerostomia, fever, inadvertent weight loss, new joint pains.

Eye drop:
Systane ou every day
Allergy drops as needed
Lumify as needed

Objective:
Visual Acuity (Snellen - Linear)
Right Left
Dist cc 20/20 -2 20/30
Dist ph cc N

Correction: Glasses

Tonometry
Tonometry (Tonopen, 3:13 PM)
Right Left
Pressure 20 19

Tonometry #2 (Applanation, 4:22 PM)
Right Left
Pressure 21 21

Main Ophthalmology Exam

Slit Lamp Exam
Right Left
Lids/Lashes MGD MGD
Conjunctiva/Sclera White and quiet White and quiet
Cornea + PEE, TBUT 1 sec + PEE, TBUT 1 sec
Anterior Chamber Deep and quiet Deep and quiet
Iris No NVI No NVI
Lens +NS +NS



Fundus Exam
Right Left
Vitreous Shafer negative Shafer negative
Disc No NVD. WNL, No heme/edema/pallor. No NVD. WNL, No heme/edema/pallor.
Macula No thickening. No thickening.
Vessels Normal Normal
Periphery No DBH/MA. No NVD/NVE. No RD/RT. No DBH/MA. No NVD/NVE. No RD/RT.


-NFL OCT- Fundus photo reviewed
OD: 115
OS: 114

Macular OCT: Fundus photo reviewed
Normal foveal contour OU
No macular edema or SRF OU

OPTOS Fundus Photography both eyes reviewed - Physician Interpreted Test Results


ASSESSMENT & PLAN:
1. Combined form of age-related cataract, both eyes Non-visually significant. Pt elects to monitor. Pt states they will call and come in prn any changes in vision or difficulty with ADL's. UV protection advised and encouraged.

2. Dry eye syndrome of both eyes Internal Referral to Ophthalmology
Eagle Collagen 0.4 mm Punctal plugs placed Bilateral lower eyelid puncta after RBA's discussed and consented- pt understands possible issues including tearing. CPM PFAT's QID OU. UVP and wind protection with wrap-around sunglasses. ROS negative for xerostomia, fever, weight loss, new joint pains. Advised pt should use Ultraviolet light and wind protection with wrap-around style sunglasses.
Omega 3 FA supplements if PMD okays. Artificial tear's QID both eyes.

3. Meibomian gland dysfunction (MGD), bilateral, both upper and lower lids Warm compresses, lid hygiene. Omega III FA's if PMD okays. PFAT's QID OU.



RTC per today's AVS notes.
Return immediately PRN any changes in vision, or any questions/concerns or problems.
Emphasized risks of permanent vision loss with delay in seeking care with signs/symptoms of Retinal tears/detachments.
Pt stated aloud that they understood and repeated back the signs and symptoms of RD/RT
 
Since 12 exam elements weren't done, then it would either be a 99204 or 99214. Also, there doesn't seem to be any medical necessity for the two OCT scans nor for the retinal photos, so they can't be billed to medical and would have to be paid by the patient as screening tests.

Since less than 12 exam elements were done, if you billed the 92 codes, they would have to be either 92002 or 92012. However, they reimburse less than the 99 codes, so I'd bill the 99 code instead.

Tom Cheezum, OD, CPC, COPC
 
92250 and 92134 are ALWAYS bundled and never unbundle them. These tests are often performed at the same time and only one can be billed, I would go with the one that pays more which is 92250.

While MDs and ODs can use either Eye codes 92XXX or E/M codes 99XXX, often if the dx codes are vision dx like myopia, etc. then commercial insurance and vsp will want to see that billed with an Eye code 92XXX.
 
Unfortunately, even with a pathology diagnosis, some major medical plans have again distorted the CPT codes and consider the 92 codes to be for routine exams only. I've heard of several coders who have their claim denied for this and, when resubmitted with a 99 code, they're paid with the same diagnosis codes.

Tom Cheezum, OD, CPC, COPC
 
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