Optometry Coding & Billing Alert

Published on Sat May 23, 2009 PDF

Let form and severity drive your coding choice.

Often, optometrists find themselves in a bind when coding for glaucoma patient visits. You have several options -- including eye codes, S codes, and V codes -- but choosing the wrong one for a particular scenario could lead to denials. These simple guidelines will get your practice the payment it deserves. You have four options for coding glaucoma exams, depending on the form and severity of the glaucoma. You are given a choice of using four ophthalmic visit or CPT codes (or "eye codes") (92002-92014, Ophthalmological services: medical examination and evaluation ...), 10 evaluation and management (E/M) codes (99201-99215, Office or other outpatient visit ...), two HCPCS S codes (S0620 and S0621, Routine ophthalmological examination including refraction ...) and two G codes (G0117 and G0118), or combinations of these. You cannot use any combination of these on the same day, warns David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. "In coding any patient/physician encounter, you main goal is to bill a code that reflects the type of chief patient complaints or reason for the office visit, and the amount and difficulty of the work done by the doctor," says Gibson.

S0620 and S0621: If a glaucoma patient appears in an optometrist's office for a check up and has no complaints about his eyes (even with the doctor's intensive questioning), then this is a routine exam, no matter what the optometrist finds wrong with the patient. "If the patient had no complaints, no matter how minor, the exam is considered routine," Gibson says.

Report routine exams with the HCPCS S codes (S0620 for new patients and S0621 for established patients). A routine exam that uncovers cataracts or pressures in the 40s is still routine if the patient had no complaints, concerns, or previous diagnoses of significant eye problems, Gibson says.

"The main problem with S codes is that not all insurance companies recognize them, so you need to know how each payer you work with wants routine care reported to them, assuming they pay for routine eye care," says Gibson.

Use Medicare's G codes (G0117 for a screening furnished by an optometrist or ophthalmologist, G0118 for a screening furnished under the supervision of an optometrist or ophthalmologist) for patients with no previous history or diagnosis of glaucoma, but due to the their age and race, are concerned about their own chances of having the illness. "This is not a routine exam, as they have an actual concern about the health of their eyes and it is not medical since they haven't ever been diagnosed with the illness or had another eye-related problem to deal with," Gibson explains.

V-code benefit: For a screening, report G0117 or G0118 with ICD-9 code V80.1 (Special screening for neurological, eye, and ear diseases; glaucoma). "Code 365.x (Glaucoma) is used as your primary diagnosis if you find glaucoma during the exam; however, a secondary diagnosis from the V code area will be helpful to get by Medicare edits and eliminate the need for a paper claim and report," suggests Alice Marie Reybitz, RN, BA, CPC, CPC-H, a healthcare coding and billing consultant based in Belleair, Fla.

The advantages to reporting these two G codes are that the claim pass edits and be paid as the screening exam. "No level visit to prove, no ophthalmic visit to deal with," Reybitz says.