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Optometry Coding & Billing Alert

Palmetto Weighs in:

E/M Codes Vs. Eye Codes

Many optometry practices struggle with the question of to use standard E/M codes for their patient visits or the more specialized ophthalmological services codes — but in the end, the choice is yours, said Palmetto GBA’s Cyndi Wellborn, RN, during a November webinar on billing optometry visits.

“Optometrists can choose which set of codes to use,” Wellborn said. “During our research, we found several articles that give coding examples. One source indicates that the general ophthalmic codes would be preferable to E/M codes for approximately 75 percent of visits and that documentation requirements for the ophthalmic codes are more easily met and their reimbursement levels are slightly higher for comparable codes.”

Some sources say that 99212 would be most appropriate for minimal level visits such as quick conjunctivitis checkups, Wellborn said. “CPT® code 99214 may be used following serious eye diseases as long as the MDM is moderate and medical necessity exists to perform nine of the elements.”

Both eye codes and E/M codes require medical documentation, they use the same definitions of a new patient vs. established, and both require an identifiable signature. “Optometrists and ophthalmologists can compare their documentation with the requirements for both sets of codes to choose the most appropriate one based on the reason for the visit and the documentation in the medical record,” Wellborn said. “Some sources say that providers that only use general ophthalmologic codes may be costing their practices money and may fail audits due to upcoding or downccoding.”