Ophthalmology and Optometry Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.


Question: We bring our glaucoma patients back every four months for a glaucoma check. We have been billing these as intermediate exams, but we are wondering if this is correct. The coding manual states that intermediate exams should present a new problem or diagnosis, therefore these rechecks would not qualify. Would it be better to code these as level three established patients? If we change their drops would that qualify as an intermediate exam? Also, every so often the doctor dilates a patient to refract them. Would this yearly dilated exam qualify as a comprehensive exam? What about the patient history? What should be included to code for the proper exams?

Pennsylvania Subscriber


Answer: In reference to the Medicare program, there is no national policy that states what is required to bill the comprehensive services of 92004 and 92014 or the intermediate services of 92002 and 92012 (also known as the eye codes). When a national policy is not in place, the local Medicare carrier that processes your claims is allowed to create a Local Medicare Review Policy (LMRP). Most carriers do have a LMRP that states what documentation is required for the eye codes. A few carriers have adopted the language from CPT that you reference: Intermediate ophthalmological services describe a level of service pertaining to the evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination ...

If your carrier is using that language as the documentation requirements, then you are correct, a return glaucoma visit that did not involve a new diagnostic condition or management problem would not satisfy the criteria.

However, note that one of the two examples given for an intermediate examination is of a cataract recheck that does not have a new problem. Most Medicare carriers consider 92012 an appropriate code for interval checks of known diagnostic conditions requiring periodic review. To determine what the local policy is, contact the provider relations department at Medicare and ask them if they have an LMRP for the eye codes. If they tell you they do not know, then request the Medicare Bulletin numbers that have referenced the four codes. By knowing the bulletin numbers, you can review past bulletins for any mention of a policy.