E/M Codes vs. Ophthalmoogical Codes:
Which Are Ethically More Profitable for Your Practice
Published on Tue Dec 01, 1998
How do ophthalmologists decide whether to use E/M codes or eye exam codes for a patient? There arent any written guidelines on this, but we talked to three coding experts to get some tips on deciding which codes to use.
First of all, the documentation guidelines for E/M codes are still in flux. The most recent set was issued in 1997, and had been scheduled to be published in CPT 1999. But they have been withdrawn because there was so much controversy over the numeric formulas -- counting criteria in order to bill for a certain level. For now, providers can use either the 1995 guidelines (the ones published in CPT 1999) or the 1997 guidelines, but they must be in compliance with one set or the other.
(Tip: The 1995 guidelines would only be an advantage to an ophthalmologist if he or she were performing whole body examinations. Otherwise, it is more advantageous to use the 1997 documentation guidelines, because they have the eye exam criteria. With these criteria spelled out, at least youll know what the Medicare auditors will be looking for.)
However, the Health Care Financing Administration (HCFA) has told providers that it will be continuing random prepayment audits based on whichever set of guidelines you choose for your practice. The revised guidelines, expected in late 1999, will include numeric formulas as do the 1997 ones. So many ophthalmology practices have decided to use the 1997 guidelines now.
Historical Note: Up until three years ago, 80 percent of ophthalmological practices used the four eye exam codes only. What happened then? A big change in RVUs for E/M codes -- more money for office visits and consulting and less for surgery. The E/M codes are more lucrative than they were, and, at higher levels, more remunerative than eye exam codes. So, if your clinical actions and documentation can justify it, our interviewees advise going with the E/M codes.
Eye Code Documentation Guidelines Vague
In defining the term comprehensive (used to determine the complexity of an eye exam), the CPT states that such services often include various items. This term means its not mandatory, says Riva Lee Asbell, a consultant in ophthalmology coding based in Philadelphia. While most physicians like the idea of vague documentation guidelines, what has happened is that the Medicare carriers have moved in on this vagueness with their own formulas. More than half the states now have policies for the eye codes, says Asbell. The carriers have definite policies about different elements that are needed. The average policy says that three to seven elements constitute an intermediate exam, and eight or more constitute a comprehensive exam.
Superficially, it seems much easier to comply with the basic rules of the [...]
