Coding and billing for the patient with diabetes presents unique challenges to optometric offices. Follow these simple guidelines to avoid many of these issues.

Take note: The following guidelines refer only to Medicare Part B. Before submitting claims, contact your local insurance carriers to be sure youre compliant with their guidelines and policies.

In eye care, two distinct sets of diagnostic codes are used for patients with diabetes: 250.XX and 362.XX. For patients who dont have retinal complications related to their diabetes, use the 250.XX series. Use 362.01 for patients with background diabetic retinopathy or 362.02 for patients with proliferative diabetic retinopathy. Be mindful that in 2005, the Centers for Medicare & Medicaid Services (CMS) updated the rules for coding diabetic retinopathy by incorporating a dual diagnosis requirement. So, if the patient has diabetic retinopathy, you must code the type of systemic diabetes as well.

In coding the office visit, be sure to use the CPT code that best reflects the patient history, level of physician work, and management options documented in the record. Either the outpatient evaluation and management codes (992XX) or the ophthalmological visits codes are appropriate.

When patients are sent to you by their primary-care physician or endocrinologist for a dilated retinal evaluation, use the outpatient consultation codes (99241 to 99245). Be sure that your record clearly documents the request for consultative services and that youve followed all the CPT and CMS consultative guidelines prior to submitting the claim.

Due to the variety of ocular complications that patients with diabetes can encounter, you may need to perform additional evaluation and testing procedures. Appropriate and timely delivery of care should never be compromised; however, you need to be aware of the National Correct Coding Initiative. The NCCI edits identify which CPT codes can and cannot be billed on the same date of service. So, to maintain compliance with these regulations, you may need to schedule appointments for additional testing at a later date, if clinically appropriate. The NCCI edits take precedence over a specific carriers local coverage determination.

Every patient with diabetes requires a dilated retinal evaluation at least annually. This procedure is considered inclusive of the office visit and should not be billed as extended ophthalmoscopy (92225 or 92256) unless you meet all the documentation requirements associated with these codes. Review the documentation guidelines for extended ophthalmoscopy prior to submitting claims, as they differ between carriers.

In 2007, CMS established the Physician Quality Reporting Initiative (PQRI) to document evidence-based measures of care. There are currently three different measures related to eye care and patients with diabetes. Although PQRI is a Medicare Part B voluntary program, its the first major attempt by CMS to move to pay-for-performance protocols. In reporting the performance of these measures, you must use CPT Level II codes. These codes do not have any monetary value associated with them, although a bonus incentive may be tied to their usage.

In completing the claims, be sure to list the appropriate Level II codes on the lines following the listing of the CPT I codes for services you have performed during the encounter. Assign zero dollars for the charges reported in box 24F for the CPT Level II codes. For a complete listing of PQRI-related codes, go to the Web sites for the American Optometric Association or CMS:,

Because optometrists are often the entry point into the eye health arena, they frequently have to address the needs of patients with diabetes. By following these suggestions, you can skip many of the hurdles in submitting claims for these patients.

Vol. No: 145:09Issue: 9/15/2008