Boost Your Understanding of Eye Examination Codes
Apply your code knowledge to real-world scenarios. Ophthalmology and optometry have the distinction of a specific set of exam codes, known as eye codes, used for coding both routine/refractive and medical exams alike. Sometimes characterized as routine, complete, or comprehensive eye exams, these codes encompass a thorough exam of the complete visual system instead of focusing on one component as determined by the patient complaint or recall plan. Read on to learn what is needed to report each eye exam code. Get to Know the Eye Exam Codes The comprehensive eye exam codes include: One or more visits? Because comprehensive exam codes 92004 and 92014 require dilation for examination and because patients may choose to defer dilation, the physician may elect to postpone billing until the patient returns for dilation and completion of the exam. In this scenario, the whole of the exam is extended over two visits and coding is contingent on the patient returning for exam completion. Physicians should make their own determination about billing this way; if the patient cancels or otherwise does not return for dilation, the physician may miss an opportunity to bill an intermediate eye code for the work already done. New or established? Criteria for new and established patients follows the same guidelines for both office/outpatient evaluation and management (E/M) service codes and eye codes. A patient seeing a physician for the first time, or who has not seen the physician (or another in the clinic) for at least three years, is considered new. All other patients are established as they return for continued care. Like E/M coding, certain criteria need to be met to achieve each threshold of exam level. Unlike E/M coding, criteria are more stringent and specific. A chief complaint, history and general medical observation, some or all components of an eye exam as detailed below, and initiation or continuation of a treatment plan are all required. A comprehensive eye exam requires a chief complaint to include history of present illness or a reason for the scheduled follow-up, ocular history of both the patient and the family, general medical observation including allergies, and social history. This information is generally captured by a nurse or ophthalmic technician, and should be reviewed and updated by the physician relevant to the exam. Once the workup is completed, the physical examination of the eye begins. Some of these elements may be completed by the tech, others by the physician. According to the American Academy of Ophthalmology (AAO) eye visit code checklist, all 12 of the elements below must be completed and documented for a comprehensive code. More than three, but less than 12, qualifies for an intermediate code. Examination of the fundus, which is the back of the eye including the retina, macula, and optic nerve, occurs when mydriatic (dilating) drops are instilled in the eye to force expansion of the pupil, enabling the physician to use a high-powered lens to view the back of the eye. Contraindication of dilation, when documented, may still support a comprehensive exam but is payer-dependent. Angle closure glaucoma, allergy to drops, trauma, and pregnancy are some valid contraindications. Patient deferral or refusal is not a contraindication. Finally, the documentation needs to cover a treatment plan, which includes, but is not limited to: The intermediate exam codes below follow the same workup criteria, must meet at least three of the 12 elements listed above, and must include a treatment plan: Which lens is better, 1 or 2? Code 92015 (Determination of refractive state) happens when lens powers are trialed to arrive at a glasses prescription. Although this occurs within the context of an eye exam, this service is not considered part of the exam code and is separately codeable. The service is statutorily excluded for Medicare patients; commercial payers have various coverage policies, but often the financial liability ultimately falls to the patient. It is important that patients understand their anticipated responsibility, as the service is necessary to establish a glasses prescription. Put Your Knowledge Into Action Scenario 1: A new patient presents for a comprehensive eye exam. They haven’t had an eye exam since they were a child and have never had problems with their vision. They have no health concerns nor ocular complaints. But they turned 40 years old recently and they notice that their vision isn't as good as it used to be when reading a book or magazine, or even a label on a cereal box. A comprehensive history is taken, including the patient’s own health as well as familial history of ocular conditions. Their IOP is checked, their visual acuity is checked, their eyes are dilated, and a thorough exam is completed from conjunctiva and cornea to the optic nerve and retina. Ultimately the patient’s ocular health is excellent but as happens to many when reaching a certain age, they have presbyopia (a decrease in the ability to focus on close objects) and need to start wearing reading glasses. A spectacle prescription is issued and the patient is recalled for annual exams. Because the patient had a complete exam through fundus with a treatment plan (glasses and annual exams), the exam meets the criteria for 92004. CPT® code 92015 is also reportable for the refraction for glasses. Scenario 2: The next patient is an established patient of the clinic returning for a scheduled IOP check. They are followed closely for primary open-angle glaucoma, but do not currently take any medication for the condition. Confrontational visual fields are taken, the eye is numbed and pressure is taken at the slit lamp with a tonometer, a device expressly used to take eye pressure readings. While at the slit lamp, a basic exam is also done including anterior chamber, cornea, iris, and lens. The patient is found to have stable pressure within normal range and no other ocular concerns are found. No medications are necessary, and the patient is given a return to clinic order for another IOP check in four months. Their pressures will be continuously monitored and managed as necessary if they elevate in the future. As more than three components of the eye exam are met, but not all 12, an established patient intermediate exam is coded with 92012. Across all specialties, across all physician types, E/M codes are coded daily for many types of medical exams. In the unique world of eye care, a second set of codes expands the field, allowing for maximum reimbursement for every exam type. Knowing how and when to use eye codes captures the work performed specific to eye examinations and will increase revenue opportunities for the eye care physician. Christine Killeen CPC, CPB, COPC, Contributing Writer
