Wiki Yearly Comprehensive Eye Exam for Diabetic Patient

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kathy a

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I am having issues with the Comprehensive eye exam codes. I have Diabetic patient's who are coming in for their yearly exam. The physician performs a complete exam. He will put at the end; "no diabetic retinopathy in both eyes". I know it would be considered comprehensive if an OCT, or other special testing is done. What if he doesn't do any special testing. What code should be used? Since it is only the eyes that are examined, and the medical decision is for 1 stable condition would that make it a Level 3 E& M code ? Your help would be greatly appreciated.

Kathy Albert,CPC
 
You could bill it as a 92014 or a 99214, based upon the documentation in the record, since you say these are annual comprehensive exams. You DO NOT have to do an OCT or other special testing for it to be considered comprehensive. Your ICD-10 would either be E10.9 or E11.9, based upon the type of diabetes and you would also have to use the appropriate Z codes for the insulin or oral hypoglycemic based upon the new guidelines for these issued effective 10/1/17.

Tom Cheezum, O.D., CPC, COPC
 
Comprehensive Examinations without Initiation of Medication or Special Testing

I thought with a Comprehensive Exam it states," Medical Examination and Evaluation with Initiation of Diagnostic and Treatment Program"? He is doing the exam only. He is not giving any medication and is not doing any testing. He does dilate the eyes for the Slit Lamp exam. He states at the end that he will see the patient back in one year?? Thanks

Kathy Albert,CPC
 
Kathy,

I'm assuming your physician is either an OD or an ophthalmologist? If so, they can use the 92014 exam code. The "treatment" could just consist of an order to monitor the patient at certain intervals to see if any DR changes develop.

Tom Cheezum, O.D., CPC, COPC
 
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