Wiki Eye Exam vs. E/M codes

[jennbrad]

I work for an FQHC in CA and we just brought on a new Optometrist in our clinic and there seems to be some confusion on coding selection. I apologize for the lack of knowledge here but if patient is being seen for an actual problem with their eye then the correct code choice would more than likely come from the E/M section, but if patient is just being seen for a routine eye exam then the correct code choice would come from the Ophthalmology code section, is that correct on a general level? Thank you in advance for anyone's help with this.

 

[Cheezum51]

The 92xxx code definitions state that there is an initiation of treatment that takes place. Therefore, to me, if no treatment or testing is required for such things as glaucoma or cataracts, then 99xxx codes should be used as long as the documentation supports the code.

Treatment may also consist of prescribing eyeglasses but if there are only refractive codes, then medical carriers won't pay for those exams in most cases.

All of that being said, there is a great deal of flexibility from most carriers for eye specialists to use either the 92 or 99 codes, even if no treatment is initiated.

The determining factor in most cases comes down to whether the documentation supports the history, exam and MDM requirements for the 99 codes. If it doesn't then you are left using the 92 codes so you don't run into problems with possible upcoding accusations.

Tom Cheezum, O.D., CPC, COPC