Ophthalmology and Optometry Coding Alert

Report general ophthalmologic codes when they best describe the service

When your ophthalmologist examines and evaluates a patient in your office, you've got some coding choices to make. You can report an E/M code (99201-99215), or you can choose an eye code (92002-92014).
 
The choice becomes difficult when there is a code in both series to describe the physician's work. Picking the right code to report an eye exam depends on exactly what the ophthalmologist examines and his reasoning. Check Out Documentation First CPT instructions tell you that you should pick the code that most clearly describes the service your ophthalmologist performs.

Note: There is no mandate that states that you must use the ophthalmology codes instead of the evaluation and management codes.

Experts warn: Avoid the temptation to code the office visit based on the highest relative value unit (RVU). If the physician is strictly evaluating the function of the eye, you should report an eye code (92002-92014). If, however, the ophthalmologist is evaluating the eye as related to a systemic disease process, report the appropriate E/M code, says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.

How it works: If a patient comes in for what he often refers to as his "yearly" exam and he has no complex medical problems, you would use the eye codes, says Rita Knapp, CPC, chief compliance officer and senior billing specialist at Abrams Eyecare Associates in Indianapolis. If a patient comes in for a brief or simple visit for a specific problem or a very complex set of problems, use the E/M codes, she says. "The final choice would depend on the presenting problem(s), management options, and degree of medical decision-making."

Example 1: A new patient presents complaining of blurred vision (368.8, Other specified visual disturbances). The ophthalmologist performs a comprehensive examination, including checking the patient's visual acuity, gross visual fields, ocular mobility, retinas and intraocular pressure. Since this is strictly an examination of the eyes' function, you should report 92004.

Example 2: A patient with chronic blepharitis (373.00, Blepharitis, unspecified) comes in due to a recent foreign-body sensation. During the case history, the patient mentions a recurring headache (784.0, Headache). The patient had an unremarkable comprehensive exam four months ago, and you don't think it's necessary to do another dilated exam. A slit-lamp exam reveals a lash rubbing the cornea on the painful eye (930.0, Corneal foreign body). Refraction indicates a significant increase in hyperopia (367.0, Hypermetropia), which may explain the headache.

You can report an E/M code -- as long as you meet the higher standard of documentation for the E/M codes. Be sure to document the date of onset, frequency and duration of symptoms, level of discomfort, whether the condition is improving, [...]