Billing complete exams

rbassett

Contributor
Messages
18
Location
Coeur d'Alene, ID
Best answers
0
I have been told that billing for a complete exam (92004/92014) more than once per year would be “upcoding” and could potentially be cause for an audit if used. One of the providers I code for is a retina surgeon. I review his notes for each exam and he is very thorough and almost always hits the criteria for a complete exam on every visit for a patient due to the high risk nature of the diseases his patients normally have. Am I okay to be billing 92014 on say a second or third visit, or would that be cause for alarm for payers? They want me to instead bill 92012 for every visit the rest of the year after a 92004/92014 is billed for a patient which I think is actually “undercoding.” At the very least I should be able to bill for a 99213 or 99214 if the criteria is met for those. Please let me know what you think.
 

jbmedbilling

Guest
Messages
2
Best answers
0
I bill for a retina specialist as well and regularly bill the 92014 when documentation warrants it. I think it is appropriate to bill according to what is documented. Hope that helps.
 

dkeown

Guest
Messages
115
Location
Lexington Kentucky Chapter
Best answers
0
I have been told that billing for a complete exam (92004/92014) more than once per year would be “upcoding” and could potentially be cause for an audit if used. One of the providers I code for is a retina surgeon. I review his notes for each exam and he is very thorough and almost always hits the criteria for a complete exam on every visit for a patient due to the high risk nature of the diseases his patients normally have. Am I okay to be billing 92014 on say a second or third visit, or would that be cause for alarm for payers? They want me to instead bill 92012 for every visit the rest of the year after a 92004/92014 is billed for a patient which I think is actually “undercoding.” At the very least I should be able to bill for a 99213 or 99214 if the criteria is met for those. Please let me know what you think.

Depends on the patient's insurance: Kentucky Medicaid and EyeMed (to name a few) will only allow one complete exam per calendar year. Other carriers vary as to what they will allow.

David E. Keown, CPC, OCS
 

rbassett

Contributor
Messages
18
Location
Coeur d'Alene, ID
Best answers
0
I just found on Medicare's mutually exclusive edits spreadsheet that 92014 is allowed once per 3 day period!
I also think some of the confusion comes from the fact that usually you can bill one 92014 with a VISION dx per year to vision plans.
 
Top