It is easy to get excited about buying a new piece of diagnostic equipment, developing new diagnostic skills or simply refining the skill sets you already have. For the most part, every diagnostic procedure you do either with or without a piece of equipment has a very specific and appropriate CPT code to use. Each CPT code has a specific definition; beyond that, it also possesses a number of characteristics that are part of the CPT language for a specific procedure. The AMA system provides a standard language that accurately communicates exactly what took place in a patient-physician encounter. 

The only way that you can describe to the world outside your practice what you did during a patient encounter is with a simple five-character code. CPT codes, by definition, are all five digits, unlike HCPCS Level II or Category III codes. You can alter the definition and characteristics of a CPT code to better fit the circumstances that occurred during the patient encounter by using a modifier to describe anything outside of the normal performance of that procedure. Use the CPT code that is highly specific to the procedure you are performing to keep an accurate medical record and avoid problems.  

Adequate Answers

About 10 to 15 times per month a doctor or their staff will ask me what CPT code they should use for a specific diagnostic procedure or office visit. For example, a physician bills for an eye exam. What kind of eye exam was it? There are currently 15 different codes that could describe an eye exam—each with a specific definition. 

In order to code your eye exam, you need to look at what was done with the patient and then match that to the most specific CPT code/definition that you can find. It troubles me that most ODs always default to a 920X4 level of service, even if the medical record demonstrates that the definition of the service was never met. The excuse I get from those doctors is that it’s the only code they know and they always use and get paid for it, neither of which are adequate answers in a malpractice case or insurance audit.

Another timely example is the codes for extended ophthalmoscopy introduced in January 2020. Note the difference in the procedures’ descriptions:

Prior to January 2020

  • 92225: Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial.
  • 92226: Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; subsequent.

Both codes have been unilateral in nature, and medical necessity for each eye had to be clearly established in the medical record. The codes also required a drawing of specific size, traditionally with colored pencils, to denote various anatomical structures and markers as well as include an interpretation and report.

January 2020–Current

  • 92201: Ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.
  • 92202: Ophthalmoscopy, extended, with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.

Consider the change due to region of retina examined and the change to a unilateral/bilateral status. Note that 92201 requires the use of scleral depression, whereas the older codes did not specify examination techniques, and, consistent with previous requirements, both tests must have detailed drawings of the respective areas of examination and concern. Additionally, a CCI edit precluding the use of 92201 and 92202 with fundus photography (92250) on the same date of service is anticipated.

Enhancing your diagnostic skill set or purchasing new diagnostic equipment requires that you use the CPT code that most accurately reflects the service performed during the patient encounter. Not only does the code govern your reimbursement based upon the collective relative value units associated with the procedure, but the other stakeholders in the patient care chain also rely on your accuracy and trustworthiness in following the CPT guidelines.

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Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.