Question 92 vs 99

Clemonwv

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I am needing to know where I would find documentation for clarification on when to use a 92 code for an exam vs a 99. We are receiving a lot of denials for the 92 codes being billed with medical diagnosis. I have been told that 92 codes should not be used when a patient comes in for follow ups for a medical condition but I need documentation to show the providers if this is the case.
 

Cheezum51

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Your denials aren't really correct. The 92 codes may be used when a diagnostic and treatment program is being initiated or continued. So, for example, if a glaucoma patient is being seen for follow up and the treatment and diagnostic program is being continued, then you can bill a 92 code. Same if you are following a patient with some type of infection over the course of a few visits until the infection is resolved.

Frankly, some carriers will deny the 92 codes because, for established patients, they currently pay at a higher rate than the 99 codes.

Tom Cheezum, OD, CPC, COPC
 
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I have also had this question, and we cant seem to get a straight answer on what to do. We were told to use 99 codes for all medical claims, but to me that would raise a red flag when auditing. Why do we get denials for 92 codes?

Anyone have any recommendations for us? thanks!
 

rklub

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I am needing to know where I would find documentation for clarification on when to use a 92 code for an exam vs a 99. We are receiving a lot of denials for the 92 codes being billed with medical diagnosis. I have been told that 92 codes should not be used when a patient comes in for follow ups for a medical condition but I need documentation to show the providers if this is the case.
One of my Optometrists was told at a seminar to use only 92 codes because less documentation is needed. This does not sound right to me. As a coder, my understanding is that the 92 codes should be used when initiating or continuing a treatment plan, such as for glaucoma or an eye infection. For more serious medical issues, the 99 codes are more appropriate. Of course, with 99 codes documentation must include the History, Physical and Medical Decision Making.
 

Cheezum51

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I would disagree that the 99 codes are "more appropriate" to use for "more serious" medical issues. The 92 codes may be used when initiating or continuing a diagnostic or treatment program. Therefore, as an example of a "more serious" problem, although I consider any ocular medical problem serious, let's assume a patient has a vitreous hemorrhage which prevents the physician from viewing the retina to determine if there's a detachment or other issue which may require immediate intervention. In that case, the physician would most likely order a B scan of the eye to check for detachments or other serious problems. The doctor would be able to bill a 92 code if desired for the exam and any progress checks. Yes, less documentation may be required for a 92 code but that isn't a reason not to bill the 99 codes when appropriate.
I lecture at meetings on the subjects of billing, coding and record keeping. Sadly, I have found that several of the other speakers on these subjects at meetings tell providers the "easy way" to get paid versus services the proper way to be paid appropriately for the level of care provided. Having done many record audits for practices, I've found that the majority of providers are leaving $30k-$50k on the proverbial table because they don't bill the appropriate 99 or 92 codes for what they've done. This is usually due to hearing speakers tell doctors how to get paid the easy way versus the proper way.
 

Clemonwv

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One of my Optometrists was told at a seminar to use only 92 codes because less documentation is needed. This does not sound right to me. As a coder, my understanding is that the 92 codes should be used when initiating or continuing a treatment plan, such as for glaucoma or an eye infection. For more serious medical issues, the 99 codes are more appropriate. Of course, with 99 codes documentation must include the History, Physical and Medical Decision Making.
This is my understanding also. In order for my providers to get on board I need documentation to show them.
 

Clemonwv

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I have also had this question, and we cant seem to get a straight answer on what to do. We were told to use 99 codes for all medical claims, but to me that would raise a red flag when auditing. Why do we get denials for 92 codes?

Anyone have any recommendations for us? thanks!
I am having the same problem. I have an insurance that pays $20 for a 92 code with a medical dx because this insurance says 92 codes are Opthalmology exams only. Another insurance pays $140 for a 92 code with medical dx. I need documentation one way or anoryer
 

Cheezum51

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Clemonwv, that insurer is forcing the 92 codes on you because their level of reimbursement is woefully low and to put more money on their bottom line. Optometry/ophthalmology are the only professions which may bill either the 92 or the 99 E/M codes. I would appeal this to your state insurance commissioner or have your docs contact their state optometry/ophthalmology association to help with this. Sadly, many insurers have "bastardized" the CPT codes for their own benefit and unless someone challenges them, they continue to get way with it just to make a higher net profit. You wouldn't want their execs to have to lease Nissans for their company provided cars versus that Lexus or Mercedes would you????
 

MSCALLIE79

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American Academy of Ophthalmology has a great articles on this. Unfortunately you have to read insurance medical policy first and follow each payer guidelines. In NC BCBS has in their medical policy that 92 codes will only be reimbursed at the routine rate no matter the diagnosis. So I bill our BCBS WITH 99 codes only all other payers I usually bill 92 codes unless it's a more serious condition/disease with moderate or high complex decision making.


 

Cheezum51

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MSCALLIE79, unfortunately, you are having to play the coding game imposed by these carriers because no one is enforcing the proper use and reimbursement of the CPT codes. As I stated earlier, many carriers have bastardized the CPT system to their own benefit. As I tell those who attend my lectures, "I'm going to tell you how the record keeping and coding for patient care should be done. However, because of unfounded and unfair criteria insurers may impose on you, as long as you do what is medically necessary and record the appropriate medical record elements properly, bill the code that reimburses you at the highest level."
 
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