Ophthalmology and Optometry Coding Alert

Both sets of codes apply to eye care specialists, so understand which to use and when.

Ophthalmologists and optometrists are unique from other specialties in that eye care providers can choose between two sets of codes to report for evaluating patients in the office setting. Although there are myriad advantages to this, it can also become challenging to decide which code set to use on your claims.

Both sets of codes — the E/M codes (99202-99215, Office or other outpatient visit ...) and, in the Medicine section of CPT^®, the general ophthalmological services codes (92002-92014, Ophthalmological services: medical examination and evaluation ...) — describe office visits.

Here’s the Challenge

There is no set rule regarding when to use the E/M codes or the Medicine section codes. Before you select which code to use, you should first familiarize yourself with what each code describes and insurance policies on each set. Choose the appropriate code according to the service provided, with the following options available:

• General ophthalmological service: New patient (92002-92004)
• General ophthalmological service: Established patient (92012-92014)
• E/M codes: New patient (99202-99205)
• E/M codes: Established patient (99211-99215)

You’ll typically use the general ophthalmological exam codes when the eye care physician’s examination focuses on eye function. 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.

If, however, the physician doesn’t launch a treatment or diagnostic program, you may be better off using the E/M codes.

Check Payer Policies

Individual insurers may post policies outlining when you should use the ophthalmological services codes and when E/M codes are preferred. In addition, your insurer might note when to use the intermediate ophthalmological services codes versus the comprehensive ones. For instance, the Blue Cross/Blue Shield of Rhode Island policy makes the following specification:

“The comprehensive services include a general examination of the complete visual system and always include initiation of diagnostic and treatment programs … These services require that the patient needs and receives care for a condition other than refractive error. They are not for screening/preventive eye examinations, prescription of lenses or monitoring of contact lenses for refractive error correction (i.e. other than bandage lenses or keratoconus lens therapy). There must be initiation of treatment or a diagnostic plan for a comprehensive service to be reported. An intermediate service requires initiation or continuation of a diagnostic or treatment plan. Follow-up of a condition that does not require diagnosis or treatment does not constitute a service reported with 92002-92014.”

BCBS of Rhode Island offers the example of a patient who presents with allergic conjunctivitis controlled by over-the-counter antihistamines. The patient comes in for a preventive visit, which “should not be reported using 92002-92014,” the payer notes. In this case, the insurer prefers that you instead report an E/M code as appropriate, based on the documentation.

In actuality, billing the general ophthalmological service codes requires initiation or continuation of diagnostic procedures, and initiation or continuation of treatment programs (depending on the code selection). Also, diagnostic tests may include a refraction, visual field test, radiology, or lab work, and treatment programs may include prescribing medications or lenses, scheduling or performing surgery, coordinating treatment with another physician or facility, and patient education.

Get to Know the Nuances

In the absence of payer guidelines, many practices maintain their own internal rules. For instance, some eye care providers have told Ophthalmology & Optometry Coding Alert that they use the following criteria when selecting between the code sets:

• “Eye codes are more restrictive as to which diagnoses meet medical necessity, and the specific codes can vary by payer, whereas E/M codes don’t typically have the same restrictions.”
• “We use E/M codes for visits that have a medical element. If the exam is strictly visual and contains no medical elements, an eye code is the right choice.”
• “Eye codes have frequency edits. For example, you’re limited to billing code 92014 once per 12-month period per patient. E/M codes don’t share those same frequency edits.”
• “Verify payer guidelines. While the documentation requirement for E/M codes is standardized across most payers, the required documentation for eye codes may vary.”
• “If you meet the required elements for both an eye code and an E/M code, choose the code with the highest level of reimbursement, but not both.”

In addition, remember that in some cases, payers might reimburse you for codes 92002-92014 under the vision benefit, but would pay the E/M codes under the patient’s medical benefit. This might trigger different copays or deductible amounts, so verify all coverage rules before patients present for their appointments. That way, you’ll know what to charge them before they leave your practice following their encounter.