Ophthalmology and Optometry Coding Alert

Ophthalmologists can bill code 92014 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits) for routine checks on Medicare patients only if there is a medical problem.

Code 92014 is often used for routine checks when the patient does not have a sign, symptom, complaint or known diagnostic condition for which the physician recommended a re-check. It may be correct for that service, but the service will not be covered by Medicare.

Patients with Vision coverage (usually HMO coverage) are entitled to routine eye care, but patients with medical coverage only are not. If the service will not be covered by Medicare, then an advance beneficiary notification (ABN) form must be signed by the patient. This form essentially states that the patient was made aware that Medicare would likely deny coverage and the patient agrees to pay the service when Medicare denies it.

Check With Carrier to Determine Eye Codes

On the face of it, this may seem simple enough. But it really isnt thats why CPT has a full page of introductory verbiage to these codes explaining what it means. The eye codes (92002, 92004) for new patients call for initiation of diagnostic and treatment program. For established patients, the eye codes (92012, 92014) call for initiation or continuation of diagnostic and treatment program.

Take the example of 92014. What if the ophthalmologist is seeing a patient for a yearly visit who has a stable condition. What kind of diagnostic and treatment program is required to fulfill the requirements for a medically necessary 92014?

There is no national policy in the Medicare program indicating what is required to be performed and documented for any of the eye codes, explains Raequell Duran, president of Practice Solutions, a coding and compliance consulting company specializing in ophthalmology and based in Santa Barbara, Calif. When there is not a national policy, it is the option of the carrier who processes your claims to create what is called a Local Medicare Review Policy (LMRP), she says.

Many carriers rely on the language in CPT that precedes the eye codes, language that says an evaluation of a new or existing condition complicated with a new diagnostic or management problem for intermediate visits 92002 and 92012, and always includes initiation of diagnostic and treatment programs as indicated for comprehensive visits 92004 and 92014.

Its essential that coders check with their carriers to find out if they are using this language to process claims. If youre not sure, contact the provider relations department and ask if they have an LMRP or if they can tell you what the Medicare bulletin numbers are that reference their policy on eye [...]