Primary eye care practices often encounter issues relating to the neurological system. One of the first signs of a serious neurological issue may, in fact, be extraocular muscle (EOM) abnormalities that manifest during diagnostic testing. While basic sensory motor testing is part of any comprehensive ophthalmic examination, performing extended testing is not—but that doesn’t mean it doesn’t have a place in optometric practice.
The sensorimotor examination is a critical diagnostic test in some instances when you suspect a neurological issue. However, many individuals either misconstrue its use or simply don’t understand its definition and the coding requirements associated with it. Here’s what you need to know.
Part of the Routine
Basic sensory motor testing evaluates and assesses the ocular range of motion to determine if the EOMs move together in the various cardinal positions of gaze. This is typically indicated in the medical record of a comprehensive exam (920X4) as ocular motility. Documentation of ocular alignment is also required in the basic examination and is often noted as ortho(phoric) when normal and eso(phoric or tropic) or exo(phoric or tropic) when abnormal. In pediatric patients, the typical notation of fix and follow (F&F) is generally used to describe both visual acuity and gross motility.
As a required element of a 920X4 examination, the basic sensory motor exam represents incidental testing and is not separately reimbursed. Additionally, it is also included as an element of the evaluation and management (E&M) codes when indicated and is listed as EOM.
Beyond the Basics
When you need a quantitative sensorimotor examination, using prisms to measure ocular deviation, and the accompanying sensory function test (e.g., stereo rings, stereo fly, Worth 4-dot, Maddox rod), you should use 92060 - sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure).
This 92060 code exists to define a more extensive test and may be billed separately and in addition to the 920X4 or 992XX examination.
Keep in mind that, as with HCPCS/CPT codes, this one includes a parenthetical statement that the examination represents a “separate procedure.” The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed.
As part of the documentation of a 92060, you must make written order in the patient record that the basic sensory motor test as described above is abnormal and that more extensive testing is indicated. This is what constitutes the medical necessity required to order and perform the extended sensory motor testing. In accordance with CPT rules, an interpretation and report of the test results, effect on the patient’s condition and course of treatment are required as they would be for any special ophthalmic test performed. The notations for the test should be clearly identifiable and distinct from any office visit notes. The interpretation and report should also be clearly distinct from the assessment and plan of the office visit notes.
Repeat testing is indicated with a clear medical necessity based on new symptoms, disease progression, new findings, unreliable results from earlier tests or a change in treatment. In most cases, more extensive testing is required when the basic information gathered from the 920X4 or 992XX examination is insufficient to properly assess the patient’s status. Repeat testing is not expected for a patient who is stable, presents with no complaints or has a condition that is properly controlled.
Neurological assessments are part of every basic examination, but an extended test that both qualifies and quantifies the sensory and motor aspects of the extraocular muscles is another valuable diagnostic tool in every OD’s toolbox. Don’t be afraid to code and bill for this separately, if the need is there and you perform the test properly.
Send your coding questions to firstname.lastname@example.org.