Coding & Reimbursement

Clearing Up Eye Exam Code Confusion

By Suzanne L. Corcoran, COE

Providers, auditors and billing staff continue to question the requirements of eye exam codes. In this month's column, we will try to clear up some of the mystery.

Q. How are eye exam codes defined?

A. CPT includes four codes that specifically describe eye exams.

92002–Ophthalmological services: medical exam and evaluation with initiation of diagnostic and treatment program; intermediate, new patient.

92004–Ophthalmological services: medical exam and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.

92012–Ophthalmological services: medical exam and evaluation with initiation of diagnostic and treatment program; intermediate, established patient.

92014–Ophthalmological services: medical exam and evaluation with initiation of diagnostic and treatment program; comprehensive, established patient, one or more visits.

Q. May we use eye codes exclusively and skip E/M codes?

A. Most eye exams fit within the requirements, but not all. Very complex patients require and support higher-level E/M codes, and not all exams meet the requirements for eye exam codes.

Q. What are the requirements of an intermediate eye exam?

A. Criteria noted in CPT include:

● Evaluation of a new or existing condition complicated with a new diagnostic or management problem
● Medical history
● General medical observation
● Exam of external eye and adnexa

Q. What about a comprehensive eye exam?

A. The CPT requirements are:

● General evaluation of the complete visual system
● Medical history
● General medical observation
● Exam of external eye and adnexa
● Ophthalmoscopic examination
● Gross visual fields
● Basic sensorimotor exam
● Always includes initiation of diagnostic and treatment programs Some local Medicare policies include instructions that go beyond the basic CPT definition.

Q. What does “initiation of diagnostic and management programs” mean?

A. According to CPT, it includes “the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological procedures.” In practice, a diagnostic program involves ordering or performing any diagnostic service that is not part of your eye exam. For example: visual fields, scanning lasers, manifest refractions, or ordering lab or radiology services would constitute initiation of a diagnostic program. Checking visual acuity, measuring IOP or performing a slit lamp exam would not.

Initiating or continuing a treatment program involves providing therapy such as prescriptions, or arranging for treatment or surgery. It may involve educating patients on risk reduction and maintenance, such as diabetic management, or coordinating care with another provider.

Q. What is “general medical observation”?

A. General medical observations refer to comments in the chart describing the patient's overall systemic health or general constitution. Commonly we see notes such as: “Patient states she is healthy,” “patient states DM is well controlled,” “patient complains of recent onset of cold symptoms.” Without detailed instructions regarding documentation of the general medical observation, we believe there is some latitude in interpreting this requirement.

Q. What must we document for the medical history?

A. Unlike the E/M coding guidelines, eye exam codes do not specify required history elements. The guidelines simply indicate that a “medical history” is required and leave it up to the provider to document what is appropriate for each patient based on the presenting conditions. It is expected that the history will be commensurate with the patient's overall health and the presenting conditions.

Consider a more detailed history for patients with complex medical issues, those on multiple medications or those who report recent changes in health status. A more focused, abbreviated history is appropriate for healthier patients presenting for uncomplicated, problem focused ocular conditions.

Q. What is the utilization of eye codes in comparison with E/M codes?

A. According to 2009 data published by CMS, ophthalmologists utilized the eye codes about twice as often as E/M codes when reporting an office visit for a Medicare beneficiary.

Q. Which diagnosis codes may be used?

A. Many Medicare administrative contractors publish policies that contain lists of acceptable diagnoses. All ocular diseases and many systemic diseases that affect the eyes are contained in these policies. Refer to your local coverage policy for a current list of acceptable ICD-9 codes. Other third-party payers publish similar lists.OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.