Ophthalmology and Optometry Coding Alert

Question: Our office has been coding exams (routine exams) as 92002 and V72.0 when we don't see anything wrong. Would this raise any red flags?

Texas Subscriber

Answer: No. You may use the general ophthalmological services code 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) with V72.0 (Special investigations and examinations; examination of eyes and vision). The V code indicates that the patient presented for a routine vision exam or a preventive service. Listing no additional diagnosis tells the insurer that you did not find or treat the patient for any condition or problem.

Coverage: If a patient has a medical-only insurance policy, the plan may not cover a claim for 92002 with V72.0 as this diagnosis may be considered routine vision screening. But Blue Cross Blue Shield of Texas will pay this combination for beneficiaries who have a routine vision rider on their health insurance policies.

You might, however, raise a red flag -- or trigger a denial -- if you code a routine eye exam, in which you found no problem, with an E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). The office visit codes are typically used to report problem-related visits. Many insurers have system edits in place that will reject a screening diagnosis code (such as V72.0) with what they consider a problem-related code (for instance, 99201-99215).

Experts say: Most insurers have a preferred way of billing their routine exams. For example, Blue Cross Blue Shield of Texas will pay routine exams with a V72.0 or a refractive diagnosis using any of the 92000 codes if the patient has a routine vision benefit. The insurer also allows medical visits with the 92000 codes when coded appropriately.