Split Decision: Do You Report an Eye Exam or E/M?
Compare documentation and review guidance to help distinguish ophthalmological services from E/M services.
By Denise Caposella, CPC, and G.J. Verhovshek, MA, CPC
Providers who report ophthalmological services are in a unique position. As CPT® Assistant (September 2008) explains, “CPT® coding guidelines allow ophthalmological services to be reported with the evaluation and management (E/M) codes [e.g., 99201-99215], using the guidelines for a single system exam, or with the general ophthalmological services codes — both intermediate and comprehensive (92002- 92014).”
How, then, do you decide which set of codes to report?
Most Eye Exams Call for 92002-92014
The “simple” answer says that if the exam primarily focuses on eye function, you should report 92002-92014. For example, CPT® Assistant (September 2008) advises, “The general ophthalmological codes are appropriate for services provided to new or established patients when the level of service includes such routine ophthalmic examination techniques as slit lamp exam, keratometry, ophthalmoscopy, and retinoscopy.”
Consider a common scenario: A new patient complains of blurred vision. The provider performs a comprehensive examination, checking the patient’s visual acuity, gross visual fields, ocular mobility, retinas, and intraocular pressure. For such an examination, call on 92002-92014.
Although the general ophthalmological codes are suitable for most eye diseases and conditions, they aren’t correct every time. Sometimes, what looks like an “eye service” fails to meet the documentation requirements for 92002-92014. And higher-level services — even those involving the eye(s) exclusively — may call for E/M codes.
Bottom line: Provider documentation should distinguish ophthalmological services from E/M services.
Note: Individual payers make the ultimate decision on reporting ophthalmological services vs. E/M services. Check with the payer for specific coding instructions.
Eye vs. E/M: A Documentation Comparison
Like E/M service codes, ophthalmology exam codes distinguish between new (92002, 92004) and established (92012, 92014) patients, using the familiar “three year rule.” CPT® guidelines specify:
An established patient is one who has received a professional service from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
In other respects, the documentation guidelines for 92002-92014 are unlike — and less burdensome than — those for E/M codes.
CPT® Assistant (January 2007) explains:
Differing from the E/M codes, the general ophthalmologic services describe the physician’s activity as intermediate and comprehensive and do not require the three key components of history, examination, and medical decision-making or use the documentation guidelines of the Centers for Medicare and Medicaid Services to determine the proper code selection.
The precise documentation elements that support ophthalmology exam codes depend on the level of service provided: intermediate or comprehensive.
Don’t Overlook the History
Component in Ophthalmology Services
Both intermediate and comprehensive ophthalmological services require a medical history. An intermediate service requires either a problem-focused, expanded problem-focused, or detailed history. To support a comprehensive service, documentation for a comprehensive history is required.
Often, providers document a comprehensive exam and initiate both diagnostic and treatment programs, but documents only a problem-focused history. This results in a down-coded service.
For additional information, see the “E/M vs. General Ophthalmological Services” comparison.
Documentation Elements of Intermediate Exams
CPT® defines the minimum elements of an intermediate exam (92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient and 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) to include:
- The evaluation of a new or existing condition complicated with a new diagnostic or management problem
- A medical history
- General medical observation
- Examination of external eye and adnexa
CPT® Assistant (January 2007) adds:
To report the evaluation of a new or existing ophthalmological condition(s) that has been complicated by a new diagnostic or management problem, use 92002 for a new patient or 92012 for an established patient.
For example, the patient presents for evaluation of pain and redness in the left eye, greater than the right. Eyes are swollen, red, itchy, and with discharge that started approximately three weeks ago. An expanded problem-focused history is documented. The exam consists of visual acuity, pupils, confrontational fields, motility, adnexae, and slip lamp exam. The patient is diagnosed with blepharitis. Medication is prescribed and a follow-up appointment is scheduled. An expanded problem-focused history, intermediate exam, and initiation of treatment supports 92012 or 92002.
Pay special attention to the exam documentation. CPT® Assistant (September 2008) explains:
When performing an external examination, the physician generally examines the eye and adnexa, which may include but is not limited to the following: eyelids, lashes, eyebrows, alignment of the eye, motility of the eye, conjunctiva, cornea, and iris. Ophthalmoscopic examinations are useful to examine the ocular media, retina, and optic nerve. Examination of the visual field of each eye helps to detect any visual field defects. Confrontation fields are included in these services.
Supporting Comprehensive Ophthalmology Exams
The minimum elements to support a comprehensive service (92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits and 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) include:
- General evaluation of the complete visual system
- A medical history
- General medical observation
- Examination of external eye and adnexa (following the aforementioned CPT® Assistant guidelines)
- Ophthalmoscopic examination (dilation optional)
- Gross visual fields
- Basic sensorimotor exam
- Initiation of diagnostic and treatment programs
CPT® Assistant (September 2008) further explains:
The definition of comprehensive ophthalmological services (92004, 92014) includes a general evaluation of the complete visual system and may constitute a single service entity but need not be performed at one session. The comprehensive service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, basic sensorimotor examination and, if indicated, biomicroscopy, examination with cycloplegia or mydriasis, and tonometry as well as the initiation of diagnostic and treatment programs.
Documenting initiation of diagnostic and treatment programs is especially crucial to support a comprehensive service. Many payers will automatically down-code claims for 92004 or 92014 to an intermediate service (92002 or 92012) if this element is missing. CPT® Assistant (January 2011) confirms, “The provider must initiate or continue a diagnostic and treatment program in order to report … comprehensive ophthalmological services codes. This means that it is required and not separately reported.”
CPT® defines initiation of diagnostic and treatment programs to include:
- The prescription of medication
- Arranging for:
- Special ophthalmological diagnostic or treatment services
- Laboratory procedures
- Radiological services
For example, the patient presents with gradual worsening of vision over the last six months in the left eye. A comprehensive history is documented. Documentation consists of visual acuity, intraocular pressure (IOP), pupils, confrontational fields, motility, adnexae, slit lamp exam, and fundus exam with dilation. The patient is diagnosed with a cataract. A B-Scan is ordered and surgery is scheduled. Documentation of a comprehensive history, comprehensive exam, and initiation of a treatment and diagnostic program supports 92004 or 92014.
Tip: The Medicine section of the CPT® codebook includes examples of intermediate vs. comprehensive ophthalmological services under the section heading “Ophthalmology” (92002- 92499).
Comprehensive Service May Include Multiple Visits
Per CPT®, comprehensive exams may be provided over multiple visits, as necessary:
To report the evaluation of the complete visual system and treatment over the course of one or more visits, use 92004 Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits for a new patient or 92014 … comprehensive, established patient, 1 or more visits for an established patient.
In other words, you can complete the examination over several visits in a day, or over the course of two or more days. For example, this might occur if a patient declines to be dilated during the initial examination, and returns later that day (or the next) to complete the dilated examination. CPT® Assistant (September 2008) confirms, “The definition of comprehensive ophthalmological services (92004, 92014) includes a general evaluation of the complete visual system and may constitute a single service entity but need not be performed at one session.” [emphasis added]
Note: Many payers place frequency limitations on 92004 and 92014; for example, allowing a maximum of two comprehensive services per year. Check with your individual payer for guidelines.
All Ophthalmological Exams Bundle Related Services
Gross visual field testing, visual acuity, and corneal topography are part of the general ophthalmological services, and should not be reported separately (see CPT® Assistant, August 1998). The CPT® codebook further explains:
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.
When to Turn to E/M Codes
Where documentation does not support the elements of either an intermediate or comprehensive ophthalmological service, or when medically relevant documentation supports the documentation elements and medical necessity, turn to the E/M codes. For instance, Blue Cross & Blue Shield of Rhode Island specifies:
Follow up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014. For example, care of a patient who has a history of self limited allergic conjunctivitis controlled by OTC antihistamines who is being seen primarily for a preventive exam should not be reported using 92002-92014. A patient who has an early or incidentally identified cataract and is not being seen for visual disturbance related to the cataract, but is being seen primarily for refraction or screening, is not receiving a service reported with 92002-92014.
Source: “Ophthalmology Examinations and Refractions: Correct Coding and Benefits Adjudication”
Per the 1997 Documentation Guidelines for Evaluation and Management Services, elements unique to a single system eye exam include:
- Test visual acuity (does not include determination of refractive error)
- Gross visual field testing by confrontation
- Test ocular motility including primary gaze alignment
- Inspection of bulbar and palpebral conjunctivae
- Examination of ocular adnexae including lids (e,g., ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes
- Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (e.g., anisocoria) and morphology
- Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film
- Slit lamp examination of the anterior chambers including depth, cells, and flare
- Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
- Measurement of intraocular pressures (except in children and patients with trauma or infectious disease)
Ophthalmoscopic examination through dilated pupils (unless contraindicated) consists of:
- Optic discs including size, C/D ratio, appearance (e.g., atrophy, cupping, tumor elevation) and nerve fiber layer
- Posterior segments including retina and vessels (e.g., exudates and hemorrhages)
- Brief assessment of mental status including
- Orientation to time, place and person
- Mood and affect (e.g., depression, anxiety, agitation)
The 1997 E/M documentation guidelines define exam levels by the number of bullet items documented, as follows:
Problem focused One to five elements identified by a bullet
Expanded problem focused At least six elements identified by a bullet
Detailed At least nine elements identified by a bullet
Comprehensive Perform all elements identified by a bullet
The levels of history and MDM follow the 1997 E/M documentation guideline standards, with the overall level of service calculated according to the intensity of the individual key components. Your E/M services may be either very simple cases or the most complex assessments, while the bulk of your visits call for the ophthalmology exam codes.
For example, the patient presents with dry eye, uses Systane®, and is also experiencing flashing and floaters. A detailed history is documented. The physical exam consists of visual acuity, IOP, pupils, confrontational fields, motility, adnexae, slit lamp exam, and fundus exam with dilation. The patient is diagnosed with keratitis sicca, nuclear cataract, and vitreous opacities. The treatment plan includes using tears, and monitor vision for increase in symptoms or changes. No initiation of a treatment or diagnostic program by ophthalmological services definition is documented.
In this scenario, documentation supports 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity or 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity with a detailed history, detailed exam, (no neuro/psyche findings are documented), and moderate MDM.
Eye Exams Are Never Separate from E/M
You should never report ophthalmological services and E/M services during the same visit. Chapter 11 of the National Correct Coding Initiative Policy Manual for Medicare Services stipulates, “When evaluation and management (E&M) codes are reported … general ophthalmological service codes (e.g., CPT codes 92002- 92014) should not be reported separately. The E&M service includes the general ophthalmological services.”
In other words: Codes 92002-92014 are bundled to any E/M services billed concurrently.
Denise Caposella, CPC, has more than 30 years of healthcare experience and is a senior consultant with Acevedo Consulting, Inc. She has a particular expertise in coding, chart audits and documentation, and compliance. Caposella is a member of AAPC and the Health Care Compliance Association. She previously served on the Editorial Advisory Board for Cardiology Coding Alert, a national coding and billing publication of The Coding Institute. Caposella is a member of the East Orange, New Jersey, local chapter.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Ashville-Hendersonville, North Carolina, local chapter.