Pediatric Coding Alert

"The addition of two new vision screening codes 99173 in 2000 and 99172 in 2001 has caused confusion among some pediatricians concerning which code should be used under which circumstances. Although the American Academy of Pediatrics (AAP) strongly recommends pediatric vision screenings, and has lately received a grant from the federal government to combat barriers to such screening, only 21 percent of preschool children are screened for vision problems. To offer this service to patients, however, pediatricians need to know how to code correctly and be paid for the exam.

The most appropriate code to use for vision screening in primary care pediatrics is 99173 (screening test of visual acuity, quantitative, bilateral [The screening test used must employ graduated visual acuity stimuli that allow a quantitative estimate of visual acuity (e.g., Snellen chart). Other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive medicine services). When acuity is measured as part of a general ophthalmological service or of an E/M service of the eye, it is a diagnostic examination and not a screening test.]). The correct ICD-9 code for 99173 is V72.0 (examination of eyes and vision).

Avoid 99172

CPT 2001 has added a second visual screening code, 99172 (visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision [may include all or some screening of the determination(s) for contrast sensitivity, vision under glare] ... [This service must employ graduated visual acuity stimuli that allow a quantitative determination of visual acuity (e.g., Snellen chart). This service may not be used in addition to a general ophthalmological service or an E/M service]). This code is for visual function screening, but it is not for use by pediatricians in screening children for developmental visual problems. The code was requested by occupational medicine practitioners, and is for use only in screening pilots and other professionals whose vision abilities are imperative to job requirements.

Bill Vision Screen With Preventive Medicine Codes

Code 99173 may be billed along with the preventive medicine codes (99381-99385 and 99391-99395) to ensure adequate reimbursement for vision screenings. For example, a 3-year-old established patient comes in for a checkup (99392, periodic preventive medicine re-evaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient; early childhood [age 1 through 4 years]). If the pediatrician performs a vision screening during the check-up, he or she may bill 99173 in addition to 99392. You do not need to use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when you bill 99173 with a preventive medicine service because the code descriptor for 99173 specifically refers to its use along with preventive medicine services.

Although the pediatrician is most likely to perform the screening during a well visit, there are other circumstances under which you might use 99173 alone. If, for instance, the patient is attending a summer camp that requires vision screens for every child and the sole reason for the office visit is the screen you would code only 99173.

Use 99173 Only for Screenings

Physicians should not use 99173 if a patient complaint led to the visual acuity testing. If there is a complaint, the test is no longer a screening exam, but a diagnostic test.

If, for example, the school asks a parent to have the childs vision tested because the child is having trouble seeing the blackboard, you should not use 99173; instead, use the appropriate-level evaluation and management (E/M) services code (99201-99205 or 99211-99215). In another example, if a child falls and hurts his or her eye, and complains of blurry vision, any visual acuity test would be a diagnostic test rather than a screening, and 99173 would not be proper coding. Even though you may administer the same test as for a screening, you cannot bill 99173 if the test is performed pursuant to a complaint.

Sure-Sight Vision Screener Not Used for Screens

The code descriptor for 99173 specifies quantitative estimate of visual acuity. Although this means that use of a simple paper wall chart will not justify use of 99173, Dont let this make you think you need to use a complicated or expensive machine, says Harold Koller, MD, FAAP, FACS, chairman of the AAP section on ophthalmology, professor of ophthalmology at Thomas Jefferson University and attending surgeon at Wills Eye Hospital in Philadelphia. A projection chart is semi-automated, he explains, as is the Snellen projector chart.

For color screening you can use a book obtained from an optical supply shop that has pictures in it, Koller says. The pictures are created specifically for use with children.

The new Welch-Allyn Sure Sight Vision Screener is not a true vision screener, Koller warns. Its a refractor, he says. It is not needed for screening. Refraction tests (92015, determination of refractive state) are performed by ophthalmologists and optometrists prior to prescribing eyewear, and should not be confused with the vision screenings performed by a pediatrician.

Gaining Payer Recognition

Insurance companies generally take time to recognize new codes. This has been particularly true of 99173; many payers claim that the vision screen is included in a well visit. Although this used to be so, it is no longer the case.

Vision screening is considered an important part of good pediatric care, and pediatricians should bill for the service when it is provided. And they must pursue denials as well, stresses Richard H. Tuck, MD, FAAP, member and founding chairman of the AAP committee on coding and reimbursement. Tuck recommends that you send the payers provider representative a copy of the descriptor and CPT guidelines for 99173, highlighting the portion of the descriptor that specifies Other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive medicine services)."