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Feburary 2009


Using the”Eye Codes” for Ophthalmic Visits

Learn to code yourself to make more money and sleep better at night.

Kurt Buzard MD, Editor


I find that many ophthalmologists with whom I speak are not only using improper codes and modifiers to code the exam, but are unfamiliar with the specific examination requirements associated with each code to use it properly. Part of the problem is that the front office often chooses the code for the office visit rather than properly having the physician choose the appropriate code for themselves. Not only are we making things more difficult than necessary, but more worrisome is that these practices may fall outside the practice patterns studied by Medicare, resulting in the intense scrutiny of CMS or insurance company auditors. It has become a fact of life that the correct coding must be determined by the physician at the time of treatment.  Fortunately, simple, easy and appropriate methods of properly coding and getting payment for our services do exist.


Ophthalmology and optometry are unique in that they have more than one set of codes to describe exams. All of medicine

uses the Evaluation and Management (E/M) coding system, codes in the 992xx series based on “SOAP” charting. Only eye doctors combine a second set of codes to identify eye exams, 920xx. The correct code for a particular visit depends on the documented elements of an exam, the seriousness of the patient's condition and the extent of the history. Remember that refraction (CPT 92015) isn’t included in any of the above visit codes. Refraction is distinct and separate service that we should always bill as a separate line item on our claim form with a distinct and separate fee often not covered by medicare. Frequently referrals are coded with the 99201-99215 and consults with the 99240-99245 codes.


Many eye doctors use the eye codes (920xx codes) because of the “simple definitions” and straightforward documentation requirements particularly in the history area. In 2006 ophthalmologists utilized the eye codes on about 70% of Medicare claims and E/M codes (excluding consultations) on about 30% of Medicare claims. Although these codes won't cover every possible situation, they're probably the easiest to use for most general examinations. Some physicians think eye codes are for “refractive visits” and E/M codes for “disease visits” although medicare does not differentiate based on diagnosis (a few private insurance companies may). You'll still need to use E/M codes for services that don't fit within the guidelines for eye codes (i.e. a followup for corneal abrasion or a complex exam). The CPT recognizes that ophthalmic codes work on a principle different from E/M codes, particularly with regard to detailing all of the components of an examination:


"Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision-making cannot be separated from the examining techniques used. Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry or motor evaluation is not applicable."


Eye code visits are either comprehensive or intermediate for both new and established patients. Keep in mind the definition of a new patient is one who hasn't received any professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Below are the (most common) 920XX codes:


         * 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.





As you can see from the above table, the 92002 and 92012 codes pay the same for comparable E/M codes (992xx) but quite a bit better for the comprehensive 92004 as compared to the E/M code 99203. Also notice that the rates have gone up for most complex exams. Given the relatively simple initial descriptions for the 920xx (compared to the coding table of the E/M codes) it would seem that they would be the obvious choice. Add to that the exclusion of level five E/M codes (almost asking for an audit) and the problem seems solved. Not so fast, flip to the narrative descriptions of the eye codes and as Riva Lee Asbell has observed:


There are narrative descriptions in CPT that many of you are not aware of until you find yourself in an audit situation. These are found at the back of CPT under "special ophthalmological services." The narrative descriptions for the intermediate eye codes are as follows:


"Intermediate ophthalmological services describes 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."


The narrative descriptions for the comprehensive Eye Codes contain the following excerpted information:

"Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examination, 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.


Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision-making cannot be separated from the examining techniques used. Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry or motor evaluation is not applicable.

Initiation of diagnostic and treatment program includes the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.

Special ophthalmological services describes services in which a special evaluation of part of the visual system is made, which goes beyond the services included under general ophthalmological services, or in which special treatment is given. Special ophthalmological services may be reported in addition to the general ophthalmological services or evaluation and management services."


A serious contradiction is that the code descriptors allow use of the established patient codes for follow-up examinations, whereas the narrative description in the beginning contradicts that. In my opinion, because there is an additional statement in the narrative for comprehensive Eye Codes, "It always includes initiation of diagnostic and treatment programs," this should be adhered to when using 92004 and 92014. Riva Asbell thinks it is acceptable to use 92012 for continuation of medical treatment, such as in glaucoma follow ups.


In addition to these sort of vague descriptions are the conditions that your local Medicare provider (LMRP\LCD) may add to to make the eye codes (920xx) more like E/M codes (be sure to check your LCD descriptions). In general the reason for downcoding from a comprehensive code (92004,92014) to an intermediate code (92002,92012) is the failure to initiate diagnostic and treatment programs. Ordering of all of the special ophthalmic diagnostic tests such as visual fields, extended ophthalmoscopy etc.,and/or prescribing medication is considered an initiating a treatment program as is refraction for glasses although be aware that written interpretation of the test in question must be made (it can be in the text of the chart). In addition, the history must represent the “medical necessity” of the visit, terms such as “routine exam” or “doing well” won’t pass muster. Some of the requirements might surprise you, general medical observation/mental status (alert and well, etc.), and while it is required only for comprehensive exams, routine EOM (with cover/uncover) and confrontational visual fields should be performed by the technicians in addition to visual acuity and tonometry to be prepared for final coding by the doctor. An extra on the eye exam, in addition to the standard lid, conjunctiva, cornea, iris, a/c, optic nerve and fundus exam, be sure to add pupil (PEERLA observed with the slit lamp). Dilation is sometimes mandated by the local Medicare carrier but the effectiveness of small pupil indirect ophthalmoscopy may be acceptable. Note the option to “finish” the visit on one or more days if the patient does not want to be dilated on the day of the visit. It goes without saying that a good EMR (electronic medical record) program will significantly simplify all of this record keeping.


If you have followed the plan laid out above you now have the opportunity to bill for intermediate or comprehensive codes depending on the associated ICD9 (or soon ICD10) codes to support the visit. Be aware of the fact that most carriers will allow only one or perhaps two 92014 visits per year (check with your local carrier). Some local carriers (such as Pensylvania) dictate ICD9 codes appropriate for the level of the visit. If you bill a comprehensive visit and the ICD9 diagnosis is on the intermediate visit list, the claim will be denied. In addition, 92014 has been the subject of scrutiny by CMS both in ophthalmology and recently in optometry in Rhode Island. Be sure your office staff is knowledgeable about the difference between eye codes (920xx) and E/M codes (99xxx). The AAO website cites an example of an ophthalmologist with an untrained staff member who switched 92014 coding for 99214 (requiring different documentation) resulting in a financial loss and a re-audit within 3-6 months. Finally, if using a comprehensive visit code, the scheduled followup must be specific, prn or followup in one year probably won’t work. If you really want to code 92014, you might be advised to use 99214 with the appropriate elements in history, exam,decision making and risk just to be on the safe side. Similarly, if you are performing a simple IOP check you will probably want to downcode to 99212.


In summary, the ability to properly code an ophthalmic visit depends on the training of physician and staff with attention to the required elements throughout the process. Failure to assemble the proper elements may result in an unbillable exam at best and an audit at worst. Internal audits are essential for both yourself and any partners you may have, everyone must be “on board” for clean billing to occur. Although it is not required, a compliance plan (AAFP Protect Your Practice With a Medicare and Medicaid Compliance Program) with a designated compliance officer and a healthcare attorney is almost mandatory to review both legal agreements and billing. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) gave the Department of Health and Human Services' Office of Inspector General (OIG) and the U.S. Department of Justice (DOJ) more funding for investigating health care fraud. The CMS RAC (Recovery Audit Contractor) demonstration program has “recovered” over one billion dollars of improper Medicare billing and is set to become a permanent program (phase-in schedule). OMIC offers errors and omissions insurance as do other carriers and with the cost of defending and paying for a Medicare audit, it makes sense to have insurance. Become involved with your billing; it will save you headaches and money in the long term.