As we fine-tune our practices, we often focus so intently on coding new technologies that we forget our practice’s foundation: the office visit. Many ODs get into the habit of coding the same type of visits, which can leave money on the table by undercoding or create undue exposure by overcoding.
Eye exams can be coded at least 16 ways in an optometric practice. The 16 codes are comprised of four ophthalmic visit codes (920XX), 10 E/M codes (992XX) and two HCPCS “S” codes (S062X). Because S codes are not used for the medical management of a patient, we will eliminate them from consideration.
Ophthalmic office visits are either comprehensive or intermediate for both new and established patients. Remember, a new patient is one who has not received professional services from a physician of the exact same specialty and subspecialty in the same group practice in three years.
92002. Ophthalmological services: Medical examination and evaluation with initiation of diagnostic treatment program; intermediate, new patient.
92004. Ophthalmological services: Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.
92012. Ophthalmological services: Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.
92014. Ophthalmological services: Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
Comprehensive eye examination codes (92004, 92014). These describe a general evaluation of the complete visual system. According to the CPT definition, it “includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.”
Gross visual fields and a basic sensorimotor exam are also required for a comprehensive eye exam, while dilation is not; however, as part of the definition of each code, dilation is not a separately billable procedure should you choose to perform it.
Intermediate codes (92002, 92012). These are defined as: “an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy.” Some inappropriately use these codes to reduce the exam cost to a non-insured patient.
The E/M codes are typically used for patients with a medical complaint or a continuation of medical case management. The five levels of E/M codes are universally applicable for all medical eye care encounters; however, out of the 10 codes within this subset, only six are used routinely: 99201, 99202, 99203, 99212, 99213 and 99214.
These codes have more specific requirements regarding case history, elements of exam and medical decision-making. The higher level codes for a new patient, 99204 and 99205, require a comprehensive history, for which it is difficult, but not impossible, for ODs to qualify.
One of the most common misunderstandings is scoring the history. Properly scoring the review of systems, for example, includes only the systems pertinent to the patient encounter on that specific day. Too often, clinicians count all 14 systems toward their history score, when only a few are pertinent. When scored correctly, the highest E/M code achievable would generally be 99203 for a new patient and 99214 for an established patient.
Understanding office visit codes is critical to coding the proper type and level of examination. Don’t get into a rut by performing a particular type and level of exam out of habit. Instead, be cognizant of the type and level of care your patients need and strengthen your practice’s foundation for the future.
Send questions and comments to firstname.lastname@example.org.