Eye Exams vs. E/M Codes: Making the Proper Selection
Both general ophthalmological services (92002-92014) and evaluation and management (E/M) codes (99201-99215) describe office visits for new or established patients. So, when should you apply the ophthalmological services codes rather than the E/M codes?
Generally speaking, ophthalmology services codes focus entirely upon the eye. If the provider is strictly evaluating eye function, report an appropriate code from 92002-92014. Although the eye codes won’t cover every situation, they will suffice for most exams. In addition, documentation requirements (especially the history) are less burdensome for the eye codes, relative to E/M services.
Revert to the E/M codes for services that don’t fit within the guidelines for eye codes. For complex or very difficult cases, you should use higher-level E/M codes. Similarly, lower level E/M codes will best describe follow-up visits and examinations for uncomplicated problems.
Like E/M codes, 92002-92014 distinguish between new and established patients. The rules for determining the patient’s status are the same for both sets of codes: A patient is established if any physician in a group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months. The CPT® codebook contains a helpful “Decision Tree for New vs Established Patients” in the Evaluation and Management Services Guidelines near the beginning of the book, to help you select the appropriate patient status.
Additionally, general ophthalmological services—like E/M codes—are “leveled” to describe different service intensity. To report the evaluation of new or exiting conditions that have been complicated by a new diagnostic or management problem, use 92002 for a new patient or 92012 for an established patient. To report the evaluation of the complete visual system and treatment over the course of one or more visits, use 92004 for a new patient or 92014 for an established patient. These criteria are laid out in more detail in the CPT® codebook.
Note that individual payers may stipulate guidelines for reporting either 92002-92014 or 99201-99215. Although the above advice is generally correct, you must know your payers’ guidelines and follow their specifics.