Optometry Coding & Billing Alert

Published on Thu Apr 14, 2016 PDF

Do you know which codes should only be used with Medicare patients?

Last issue, we broke down the basics of diagnosis coding for glaucoma (“Get Familiar with All the Angles to Focus Your Glaucoma Dx Coding,” Optometry Coding & Billing Alert, Vol. 14 No. 4). Now, we’ll take a look at CPT® codes for screening and testing.

Look to Eye Exam Codes for Screening and Exam

The CPT® codes for comprehensive eye exams – 92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits) and 92014 (… established patient, 1 or more visits) – are payable by Medicare once a year for a glaucoma screening and exam, explains Alice Marie Reybitz, RN, BA, CPC, COC, CPC-I, CCS-P, Online E-learning Instructor for the American Academy of Professional Coders (AAPC), who led a seminar on the subject at CodingCon 2015.

Don’t miss: To prove medical necessity for the screening, make sure to link one of these ICD-10 diagnosis codes:

• H40.11XX – Primary open-angle glaucoma
• H40.01X – Glaucoma suspect; open angle with borderline findings, low risk.

In addition, general ophthalmological services such as gonioscopy (CPT® code 92020) and visual field testing (CPT® code 92083) are billable separately from 92004 and 92014, according to Correct Coding Initiative (CCI) edits, Reybitz says.

CPT® code 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) is payable once a year to high-risk patients, Reybitz says.

Save G0117 and G0118 for Medicare Patients

G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) and G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist) are for use with Medicare patients. Do not use these codes with commercial payers, warns Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

“Additionally, these codes would only be reported if the only reason for the encounter is to perform the glaucoma screening,” Mac says. “And prior to performing the glaucoma screening, the patient would need to meet the criteria for providing the service.”

Those eligible for the screening include:

• People with a family history of glaucoma
• People with diabetes mellitus
• African-Americans age 50 and older
• Hispanics age 65 and older.

“The glaucoma screening codes are bundled with the E/M codes and the eye codes,” Mac says. “If a patient is seen by the provider for an eye exam and glaucoma screening is done as part of the workup, you would only bill the E/M code or eye code. There would probably not be a lot of circumstances where a patient would be seen for glaucoma screening only. Perhaps at a health fair or specialized ‘screening day’ for an event. However, most of these types of events provide the work free and these codes would only apply to Medicare patient meeting the criteria anyway.”

Know the Rules for Follow-Ups and Consultations

Follow-ups: “Of course you can always choose from the E/M codes, but it is a low-level visit most times,” Reybitz says. The eye exam CPT® code 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) allows for the continuation of any treatment and the exam at an intermediate level, while 92014 allows for initiation and continuation at a more comprehensive level, she says.

Consultations: For consultations (CPT® codes 99241-99245), these three conditions must be true, Reybitz says:

• Another physician or NPP must be requesting your optometrist’s opinion and advice.
• This reason for the request must be in writing and documented in the patient’s chart as part of the consulting physician’s report.
• A written report must be provided to the requesting physician – even if he is in the same group practice. However, when a chart is shared by multiple physicians and the requesting physician has access to the chart (e.g. hospital record), the documentation by the consulting physician need only be in the shared medical record.

Stay Solid on Diagnostic Testing

When the optometrist is tracking acute glaucoma, you can bill for serial tonometry if he checks the intraocular   pressure (IOP) more than three times in the same session, Reybitz says. Report 92100 for that service.

Optometrists also often use pachymetry for glaucoma patients to determine the correlation between corneal thickness and IOP. CPT® code 76514 (Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) is inherently bilateral; report it only once whether one or both eyes are tested.