The “Eyes” Have it: Routine vs. Medical Eye Exams

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  • November 2, 2012
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Eyeglasses and eye chartby Nancy Clark, CPC, CPMA, CPC-I
Understanding the difference between routine and medical eye examinations will guide you to properly code these services and prevent your patient from receiving an unexpected bill. Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.
CPT® codes 92002-92014 indicate new and established eye exams, and are used for both routine and medical visits. The primary diagnosis code makes the distinction.
New patient:
• 92002 Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
• 92004            ...comprehensive, new patient, 1 or more visits
Established patient:
• 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
• 92014            …comprehensive, established patient, 1 or more visits
A routine visit is indicated by a primary diagnosis code of V72.0 Special investigations and examinations; examination of eyes and vision, followed by any additional diagnostic findings. For example, if an eye exam is coded as 92002 with a primary diagnosis of V72.0, it is considered a routine exam; however, 92002 with a primary diagnosis of 379.91 Pain in or around eye would be considered a medical exam.
When a patient presents for an eye exam due to poor eyesight, he may believe this service to be covered by insurance. But insurers do not consider refractive errors (e.g., nearsightedness and farsightedness) to be medical diagnoses, and many do not cover routine vision exams. Consequently, there may be confusion on the patient’s part if his insurance company denies the service.
Clear up the confusion before the service is rendered by contacting the patient’s health insurance and determining if routine vision services are covered, the frequency of coverage, and if the patient has met or exceeded his limit of routine services. Ask the patient if he has separate vision coverage under another carrier. Ensure that your patient understands the difference in exams and what his insurance covers.
Nancy Clark, CPC, CPMA, CPC-I

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No Responses to “The “Eyes” Have it: Routine vs. Medical Eye Exams”

  1. Jason says:

    eye stuff

  2. Carol Woodard says:

    How do the E/M codes come in to play for the Opthalmologist?

  3. Carina says:

    That is what I said to myself. Nancy Clark talks about two different sets of CPT codes for routine or medical, but then goes to different ICD-9 codes?????????????

  4. Amanda says:

    You need to re-read the article…
    “Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.”
    Physical exams have different CPT codes for routine (99381-99397) and medical visits (99201-99215). Eye Exams don’t, you need to use diagnoses to differentiate.

  5. Dr. John Rumpakis says:

    Chief complaint determines whether or not the eye examination is routine or medical in nature. CMS is very clear on this:
    The Medicare Carriers Manual, Part 3 §2320 reads:
    “The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.”
    Comprehensive or intermediate ophthalmological examinations performed under the contract of a refractive plan are deemed to be “routine in nature” as they are a prepaid benefit and generally exempt from the chief complaint requirement. They are not reduced services, just payable outside of the medical plan in a refractive carve out. The diagnosis has really nothing to do with the examination being routine or not, as the ICD-9 code simply describes the condition of the patient post examination.

  6. diana says:

    I work in ophthalmology…this has always been an issue for us but we are on top of it all…Some patients may have coverage for a routine vision exam paid under preventivie care on their medical insurane (anthem as an example) so we would use v72.0 as diagnosis code for 92002 thru 92014 cpt codes/ some insurances do not cover the eye refraction (cpt code 92015) which is also an important part of the eye exam

  7. chandani says:

    I am working in Group practice. When the patients come for preventive visits our family physicians do eye exam. So my question is “what is the CPT code I ca use for this type of eye exams”?. Normally, I use 99173, Is this code correct? Please advice me.

  8. penney says:

    So if a patient has an underlying medical condition such as OAG but presents because he cant see out of his glasses…how would you code it?

  9. diana says:

    Would love to see AAPC address the issue of when to use eye exam codes 92002-92014 vs E/M codes 992xx using the 1997 E/M guidelines.

  10. Cindy says:

    Well said Dr Rumpakis…and use of CMS authoritative resource. Cororan Consulting Group is a practice management consulting firm specializing in opthalmology and optometry. They are excellent and can teach you all about this difficult area. It would be a service for AAPC to members to have an educational article from CCG.

  11. Cindy says:

    correct spelling is Corcoran CG

  12. Rajkumar says:

    I am working in hospital with eye specalist. Can someone help me out what are the components of intermediate and comprehensive exam in detials, so that it will be helpful to me.Thanks

  13. Janice says:

    I work for a small practice of Ophthalmology Dr’s. We frequently have commercial insurance representatives who are confused and pay as if we are billing vision services even though our diagnosis indicate a medical procedure. Also CMS Medicare pays correctly nearly every claim. I don’t remember the last time I had an appeal with Medicare over this issue. Mainly it is the commercial insurance who do not pay correctly. Also in my opinion it is due to the lack of training that the representatives get on how to process these claims correctly.

  14. Carol Courtney says:

    Colding eye exams is not as hard as people think. What is the value of using eye exam codes 92002 – 92014 over E/M codes? It boils down to the documentation required for each level of service.
    The eye codes require that there be initiation of diagnostic and treatment program. This is the point where the eye exam codes differ from the E/M code. To use a code from 92002 – 92014 you MUST initiate a diagnostic or treatment program. This can be as simple as writing out a prescription for refractive correction, told to use over the counter eye drops, etc. The documention requirements are ONE eye element examined and noted in the record for an intermediate exam and 8 or more for a comprehensive exam. The documentation requirements favor the provider to use the eye codes over the E/M codes. There is not a straight across match from the eye codes to the E/M codes. Also, most insurances do not expect to see the eye exam codes used more than once or twice a year.
    Most insurance companies will accept the eye exam codes with a medical diagnosis and pay it under the medical portion of the contract. Using the E/M codes in the Ophthalmology practice is absolutely necessary as there is many eye diseases and disorders that must be followed closely to prevent vision loss. These generall are coded with E/M codes following the 1997 guidelines. A clear article written on this subject would be a tremendous help to many people who try and figure out which way to jump in this speciality.

  15. Rajkumar says:

    Thanks for that Carol Courtney. It was helpful to get an idea. Is there any site which is having any sample templates for this, so that we can implement and code to maximum.Thanks

  16. Carol Courtney says:

    Not sure of any one website for this information. My templates are pulled together from various sources, mostly from CMS and then put into a logical (?) order. Would be willing to share.

  17. Julie says:

    I would be very interested in any type of template that you may have put together Carol. I am a new coder and have been assigned the ophthalmology department with very limited training by the prior coder.

  18. Carol Courtney says:

    Send me a request at my home email and will either email or fax the template. It may take me several days to dig it out and make sure it is all there. You also might want to sign up for the ophthalmology list serve hosted by decision health, it is a great place to post coding questions.

  19. Denis says:

    Hi All :{>,
    I reviewed all of the posts above and from I’ve read I gather that most or all of you work for Ophthamologists or code in an Optometric or associated facilty?
    Do any of you have coding experience coding in other organizations such as the corporation I work for, which is an IHS facility (Indian Health Service)? I am always looking to pick up tips that support my expertise that will help me better serve the community I work for. What better place to do that than a coders forum, huh?
    I code for Optometry and Podiatry here (right now, mostly OPT). Diabetes is near pandemic (95% of population) within the Native American Reservations and Communities (this Rez included) and with that comes an entire spectrum of issues and manifestations associated with this systemic disease.
    Our Optometrists do perform standard/basic eye exams (anual), but the services they perform between anual eye exams goes much further than this. Whereas, procedures performed during eye exams are inclusive (using CPT 92002-92014) and cannot be coded or billed separately; such as Fundus (DFE), Computerized GDX Scans – i.e. OCT Macula/OCT RNFL, SLE, VFE and any number of procedures used to determine the progression of diabetes and glaucoma (as well as other associative eye diseases) with the manifestations that accompany these conditions.
    In conditions such as these, the encounter goes beyond the standard or basic anual eye exam into the monitoring of the progression of systemic diseases and their manifestations and any other condition(s) affecting the vision.
    I appreciate in advance the input any of you can offer. If you work/code or have experience in any facility similar to the one for which I work, please respond in kind.
    You may respond to my email addy below:
    Subject Line: “Optometry Tips”

  20. Karen says:

    Janice, I work for a health insurance company, and you are right… it is a training issue. I have been quoting benefits and eligibility for a year and a half now. If anyone ever wants to really learn a spectrum of claims processing issues come work at a call center! I see the newbies come thru and there will always be misquotes, it does come with experience. When I look at a Opth claim – I am definitely looking at the primary diagnosis to determine whether this claim has been processed under the patients medical benefit, or their vision benefit. (unfortunately the computer does not flat out tell you) – it is def determined by the Dx. If Glaucoma or cataract is the primary dx – will fall under the medical benefit and will be paid.
    Carol, your posts have been awesome, I am looking forward to obtaining my coding certification in the near future.

  21. Timothy Jones says:

    Is there a list of diagnostic codes for why eyeglasses are prescribed? Such as farsightedness or nearsightedness, cataracts, etc.

  22. Timothy Jones says:

    Codes I need are E119, H25093 & D2312 to process a reimbursement to a member of our organization! Many thanks

  23. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  24. Ronda says:

    My husband recently had a routine eye exam with a new provider. We have vision insurance but the optometry office personnel said that since my husband has ocular implants (has had them for about 30 years) they had to code the visit as medical, therefore not being covered as a well vision exam by the vision insurance. The purpose of the office visit was for a routine exam, he is having no problems with the implants. Is a medical code in this case correct?

  25. Troylene says:

    if the doctor does a exam and there is no medical dx , so its routine eye and they have a vision plan . The doctor’s dx code is H52.13 for the exam and refraction. so when i submit the exam to the vision insurance, do i also put what’s in the patients record or put Z01.00 . i know a lot of people who put the Z01.00 on all Routine eye exams . But it is not in the patients chart. It’s in there with a disorders of refraction and accommodation H52xxxxxx

  26. Eleanor says:

    I have an eye exam every two years thru Anthem. I argued with my eye doctor’s office stating I should not be charged the $45 copay. They insisted that the dr is correct because in doing the exam he put down a diagnosis! I am understanding that this exam should fall under the same category as my annual gyn exam, no copay?! Shouldn’t he be using a dx code first that states it is an annual exam?

  27. Lin says:

    Is a visual field test part of a routine eye exam? I have insurance thru BCBS/Anthem and supposedly covers one annual eye exam no charge and includes testing for Glaucoma but my opthalmalogist says it is not routine and therefore we are responsible for the cost. Also had a routine eye exam but my eye doc put a medical diagnosis so I was responsible for entire cost. I was starting a med soon that may affect my eyes, but had not at that time and my eye exam was normal. Confused about medical diagnosis since nothing was wrong with my eyes. Could understand if something showed up but until shouldn’t it be coded as a routine eye exam?

  28. Kathleen says:

    can an optometrist charge 190.00 for an eye exam when the patient came in just because his near vision was bad, but the dr. found the beginning of cataracts. A normal exam is 65.00. Now we are responsible for the 190.00 charge. My husband did not come in because he felt his vision was cloudy due to cataracts. A normal routine eye exam is 65.00

  29. Donna Bills says:

    When a patient with an increased risk of retinal detachment and a history of a retinal tear goes to see her retina specialist for an exam after seeing a flashing light, this is medical, right? Insurance company is saying it was just a routine exam that is not covered. Calling provider tomorrow to discuss their possible coding error. Thinking since there was no detachment found, thankfully, insurance is quibbling. But always before they have payed for a yearly exam with the retina specialist based on examining the láseres tear from several years ago.

  30. Ginger says:

    I went to a dr for an eye exam (quoted as $105 and my insurance covers one a year). He had a 3 page health questionnaire so he knew I was a diabetic. Thus he also performed a scanning type test which he turned in to the insurance as code 92134 and charged me my $40 co-pay for medical specialist for this procedure. The eye exam was $20 co-pay. He only turned in the 92134 billing to the insurance so his office says he owes me $20. So here is my question: can he charge for both procedures done on the same day and visit and still charge the two co-pays?