21 yr old patient with glasses arrives for annual routine eye exam with no complaints. Dr. dilates patients eyes, does quick exam, air puff test, and completes with Snellon test while patient wears their glasses. Dr. mentions to patient their eyes look a little dry but has zero concerns with this. No treatment or follow-up was provided to patient for dry eyes. Dr. also confirmed there was no change in patients' vision. How should this visit be reported? Should this be reported to the medical or vision insurance?
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Wiki Annual eye exam billed with dry eyes
- Thread starter Jennifer Kingsley
- Start date
Edmundo
Contributor
Hi Jennifer,
It's a pleasure.
Question 1. Usually when the patient is dilated, all 12 elements of the comprehensive exam (92004/92014) is documented - you will need to confirm that in the chart. If 3 or more elements are documented but less than 12, you may code CPT 92002/92012. If documentation does not meet either intermediate or comprehensive requirements, I would code CPT 99212 with having dry eyes as the primary ICD10CM.
Question 2. This should be reported to medical insurance.
How to Choose Between E/M and Eye Visit Codes - American Academy of Ophthalmology (aao.org)
Edmundo Gonzalez, CPC, COPC, OCS
It's a pleasure.
Question 1. Usually when the patient is dilated, all 12 elements of the comprehensive exam (92004/92014) is documented - you will need to confirm that in the chart. If 3 or more elements are documented but less than 12, you may code CPT 92002/92012. If documentation does not meet either intermediate or comprehensive requirements, I would code CPT 99212 with having dry eyes as the primary ICD10CM.
Question 2. This should be reported to medical insurance.
How to Choose Between E/M and Eye Visit Codes - American Academy of Ophthalmology (aao.org)
Edmundo Gonzalez, CPC, COPC, OCS
Edmundo
Contributor
Please reference this medical decision-making table when coding E/M. Best of luck in Ophthalmology!
e-m-final-determination-table-2023-version-pdf (aao.org)
Edmundo Gonzalez, CPC, COPC, OCS
e-m-final-determination-table-2023-version-pdf (aao.org)
Edmundo Gonzalez, CPC, COPC, OCS
Thank you!