Both the E/M codes (99201-99215, Office or other outpatient visit ...) and the general ophthalmological services codes (92002-92014, Ophthalmological services: medical examination and evaluation ...), describe office visits. So how should you decide which to report?
Switch to E/M Codes for Complicated Exams
Don’t choose based on the amount of reimbursement. The general rule for CPT® codes is to pick the code that most clearly describes the service your ophthalmologist renders. If you are strictly evaluating the function of the eye, report an eye code. If, however, you are evaluating the eye as related to a systemic disease process, report the appropriate E/M code.
Example 1: A new patient presents complaining of blurred vision. You perform a comprehensive examination, including checking her visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure. Because this is strictly an examination of the eyes’ function, use 92004. In this case, the proper treatment may be to continue monitoring the condition without treating.
Example 2: A patient with chronic blepharitis comes in due to a recent foreign-body sensation. During the case history, the patient mentions a recurring headache. The patient had an unremarkable comprehensive exam four months ago, and you don’t think it’s necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye. Refraction indicates a significant increase in hyperopia, which may explain the patient’s headache.
You can report an E/M code as long as you meet the higher standard of documentation for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, and other details defined in the E/M codes that the eye codes don’t specify.
Along with Medicare or other medical insurance, many of your patients might have supplemental private insurance to cover their routine eye exams.
Example 1: A patient presents for what he thinks will be a routine vision exam, but you find cataracts. Should you bill his vision plan or Medicare? Be careful: The wrong answer could get you in hot water with your patient, not to mention CMS.
When you find a medical problem like cataracts or glaucoma while doing a routine eye exam on these patients, you have a dilemma. Should you bill the patient’s medical insurance, since you found a medical condition? Should you bill the patient’s vision insurance? Or can you even bill both?
The answer depends on the patient’s reason for being there, as well as his expectations. Bill based on the patient’s chief complaint and history of present illness (HPI). If he has a specific complaint that can be attributed to a non-refractive diagnosis, then it’s a medical visit and you should bill the medical insurance.
Example 2: A patient arrives complaining of blurred vision. You find that cataracts are causing the blurriness. Bill the patient’s medical insurance with the appropriate eye exam code (92002-92014) and link it to the appropriate cataract code (366.xx).
As a secondary diagnosis, report 368.8 (Other specified visual disturbances [blurred vision NOS]).
If, however, you found no cataracts or any other condition causing the blurred vision, report 368.8 as the primary diagnosis.