Wiki 92004/92014 vs 99204/99214

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ambercragun

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Hi, I was wondering if anyone could answer a few questions for me. At your office do you bill 92004 and 92014 with medical dx codes very often? We rarely do and usually stick with 99204 and 99214. Our doctors want to try using the ophthalmic office visit codes because it isn't as strict. Everything online says that most insurances only allow these cpt codes to be billed once a year. Does anyone use them much for Medicare? Thanks
 
I worked in Ophthalmology for the past 12 years and one of my doctors only use 92004, 92012, 92014 for that exact reason. We billed all government, and commercial claims with medical diagnosis. If the patient didn't have a medical reason then the visit was covered every 12 months. example Diabetic Exam-Allowed every 12months. But when you see patients for Glaucoma, Dry Eyes, Double Vision, Cataracts, Etc we had patients who came in every 3-4 months and we got paid. The only 2 insurance's that I had a issue with wanting to consider it "Vision" was Blue Cross and Our local Medicaid, but that was not all the time. I just had to send in appeal that we are medical and not vision and we got reimbursed.

Good Luck
 
technically, the 92XXX codes should only be used when you are initiating a diagnostic or treatment program. For example, if a patient was seen for a comprehensive exam and the doctor thought the patient might have glaucoma, you would used the 92004 or 92014, depending on whether they were new or not, since the doctor would probably order further testing to determine if the pt has glaucoma. Follow up visits would probably be billed as 92012 as the doctor determined the diagnosis and treatment. If the patient was on a glaucoma drop and was seen for a pressure check, say 4 months after the doctor was happy with the initial IOP attained with that, you would use a 99212 or 99213 if all was stable and no changes were made. If the doctor decided that the IOP wasn't controlled well and changed treatment, he would be initiating a new treatment and thus would bill a 92012.

Hope this helps.

Tom Cheezum, O.D., CPC, COPC
 
Cheezum51 said:
technically, the 92XXX codes should only be used when you are initiating a diagnostic or treatment program. For example, if a patient was seen for a comprehensive exam and the doctor thought the patient might have glaucoma, you would used the 92004 or 92014, depending on whether they were new or not, since the doctor would probably order further testing to determine if the pt has glaucoma. Follow up visits would probably be billed as 92012 as the doctor determined the diagnosis and treatment. If the patient was on a glaucoma drop and was seen for a pressure check, say 4 months after the doctor was happy with the initial IOP attained with that, you would use a 99212 or 99213 if all was stable and no changes were made. If the doctor decided that the IOP wasn't controlled well and changed treatment, he would be initiating a new treatment and thus would bill a 92012.

Hope this helps.

Tom Cheezum, O.D., CPC, COPC
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Thank you! I know it's been years since you answered this but can you help me with another question? We now regularly use 92004 and 92014 with a medical dx and haven't had any issues with insurance companies paying but this past year Meritain started denying them. If the pt doesn't have vision insurance they say it isn't a covered service and if they do have vision they say that is their eye exam and then will deny when the pt actually comes in for an eye exam. I have called and complained and submitted appeals and they still will not cover it. Is there anything I can do? Or should we just bill 99 office visits to Meritain.

Thanks,

Amber
 
I'm going to guess why this is happening based upon what I've heard other ODs complain about with other major medical insurers. I'm going to assume that your office is an OD office. Is that correct?
If correct, this is what is probably happening. Mertain is basically saying that ODs can't provide medical eye care. Therefore, if you file a claim for medical eye care, probably whether you use the 99 or 92 codes, they deny it. If they have a vision plan, the insurer only wants to pay you at the vision plan rate instead of the, usually higher reimbursing, medical plan rate.
A couple of suggestions: 1) Try filing your medical eye care visits using the 992xx codes and see if they pay you. For some reason, some insurers feel that the 992xx codes are for medical eye care and the 920xx codes are for "routine/non medical" visits.
2) If using the 992xx codes doesn't help you get paid, then contact your state insurance commissioner and file a complaint with them that they are discriminating against your doctors and their legal ability to provide medical eye care under state law. You may also want to contact your state optometric association, again if your docs are ODs, to see if they have heard about this problem and have found a way to get it corrected.

Please let me know what you find out.

Tom Cheezum, OD, CPC, COPC
 
Cheezum51 said:
I'm going to guess why this is happening based upon what I've heard other ODs complain about with other major medical insurers. I'm going to assume that your office is an OD office. Is that correct?
If correct, this is what is probably happening. Mertain is basically saying that ODs can't provide medical eye care. Therefore, if you file a claim for medical eye care, probably whether you use the 99 or 92 codes, they deny it. If they have a vision plan, the insurer only wants to pay you at the vision plan rate instead of the, usually higher reimbursing, medical plan rate.
A couple of suggestions: 1) Try filing your medical eye care visits using the 992xx codes and see if they pay you. For some reason, some insurers feel that the 992xx codes are for medical eye care and the 920xx codes are for "routine/non medical" visits.
2) If using the 992xx codes doesn't help you get paid, then contact your state insurance commissioner and file a complaint with them that they are discriminating against your doctors and their legal ability to provide medical eye care under state law. You may also want to contact your state optometric association, again if your docs are ODs, to see if they have heard about this problem and have found a way to get it corrected.

Please let me know what you find out.

Tom Cheezum, OD, CPC, COPC
Click to expand...

Thanks! Yes we are an OD practice, but we do a lot of medical billing. Meritain does always pay if we use the 99xxx codes. In your opinion do you think we should just use the 99xxx codes when billing medical visits to Meritain? Or do you think it is something I should keep fighting for? I am in Alaska and every other insurance we bill pays on the 92xxx codes with medical diagnosis. :(
 
Some in insurers are just a pain to deal with and try to interpret the CPT codes to their benefit. I'm not sure how it is in Alaska but in Virginia, most insurers pay a higher fee for a 9201x established pt visit than for the 9921x codes. If that's the case there, Meritain is probably trying to avoid paying that higher fee, which IMHO, isn't legal or justified. If you have a good relationship with an ophthalmology practice near you, see if you can speak with one of their billers to see if they're having the same problem where only 992xx codes are paid for medical. If they are, maybe a few practices can get together and complain about what Meritain is doing.
Whether you fight their policy kind of depends on whether it would benefit you financially to be able to bill the 9201x codes for medical eye care. If not, you may just want to play their game and use the 99 codes until maybe the state insurance folks deal with the complaint.

Tom Cheezum, OD, CPC, COPC
 
Cheezum51 said:
Some in insurers are just a pain to deal with and try to interpret the CPT codes to their benefit. I'm not sure how it is in Alaska but in Virginia, most insurers pay a higher fee for a 9201x established pt visit than for the 9921x codes. If that's the case there, Meritain is probably trying to avoid paying that higher fee, which IMHO, isn't legal or justified. If you have a good relationship with an ophthalmology practice near you, see if you can speak with one of their billers to see if they're having the same problem where only 992xx codes are paid for medical. If they are, maybe a few practices can get together and complain about what Meritain is doing.
Whether you fight their policy kind of depends on whether it would benefit you financially to be able to bill the 9201x codes for medical eye care. If not, you may just want to play their game and use the 99 codes until maybe the state insurance folks deal with the complaint.

Tom Cheezum, OD, CPC, COPC
Click to expand...

Thank you for your reply. I will argue more with Meritain and call around. It is the same here that the 92 codes pay higher than the 99 codes. I will let you know if they ever start paying correctly.

Amber
 
That clears that up. Meritain is just trying to protect their bottom line by disallowing 9201x codes for medical eye care. In Virginia, for Medicare, the 92012 pays $14 more than the 99213. 92014 pays $18 more than 99214. You add those differences up for multiple visits for just a couple hundred patients (glaucomas or dry eye as examples) and you start to see significant amounts of money they're cheating you out of. Add that up for all the eye providers on their panel and it's saving them millions of dollars per year.

I'd really try to find out if they're doing this to the ophthalmologists as well. If they aren't, that's blatant discrimination.

I wonder what types of cars their executives are driving that the company leases for them? :)

Tom Cheezum, OD, CPC, COPC
 
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