Ophthalmology and Optometry Coding Alert

Question: Which code (diagnosis and CPT) should I use for a baseline Plaquenil exam?

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Answer: Plaquenil is the trade name for hydroxychloroquine, a medication used to treat rheumatoid arthritis and lupus. It can have adverse effects on the lens and/or retina and, therefore, the primary care physician or rheumatologist treating the condition refers the patient to an ophthalmologist for monitoring ocular changes. Use either an E/M office visit code (99201-99215) or an opthalmological services code (92002-92004, 92012-92014).) It may also be necessary to check visual fields (92082, intermediate examination, or 92083, extended examination).
 
You may also need to perform extended ophthalmoscopy (EO) (92225). However, some carriers will not pay for 92225 with the diagnosis code for Plaquenil monitoring (V58.69, long-term [current] use of other medications, or V67.51, follow-up examination; following completed treatment with high-risk medications, not elsewhere classified). In those cases, include the EO in the E/M office visit or opthalmological services code and code based on the total service rendered and documented in the visit, as well as the visual-field code. The diagnosis codes depend on whether the patient is now taking Plaquenil. If the patient has used the drug in the past but isnt now using it, code V67.51. You may need to conduct several checks after medication has discontinued to make sure latent toxicity doesnt appear.
 
If the patient is taking the drug, code V58.69; a few carriers, however, prefer V80.2 (special screening for other eye conditions). To be paid for the visit and the visual fields, use the specific diagnosis code recommended by the carrier in its LMRP. In all cases, the underlying condition may be coded as a secondary diagnosis. Some carriers indicate in their LMRPs that they prefer the underlying diagnosis to be coded as the primary diagnosis and the V code for the high-risk medication as the secondary diagnosis. Follow your carrier's LMRP instructions.

 
Answers to Reader Questions and You Be the Coder reviewed by Lise Roberts, vice president, Health Care Compliance Strategies, Jericho, N.Y.; Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.; and Jon Winders, practice administrator, Umpqua Valley Eye Associates, Roseburg, Ore.