Wiki Comprehensive Eye Exam Components

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erinmccauley90

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I was taught that it was acceptable to code a Comprehensive Eye Exam (92004, 92014) if the following exam elements were met:
-History
-Medical Observation
-Gross Visual Fields
-Basic Sensorimotor Exam
-External/Adnexa Exam
-Ophthalmoscopic Exam (Retina/Optic Disc - vitreous, macula, vessels, periphery)
-Diagnostic/Treatment Program

I was coding encounters that met this criteria as Comprehensive visits but was then told by one of my clinicians that Medicare requires more than just these exam elements. They said that Comprehensive should only be used when there is more thought involved, when the condition has changed, etc. Their concern was that if we coded based on meeting the elements above, we would be flagged for review. I am now having a hard time differentiating between when to code an Intermediate vs Comprehensive but I can't find specific Medicare requirements anywhere. Is there more to it than just meeting the elements above?
 
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What you have, in terms of exam elements, is correct. I believe what your provider is referring to is that the 92004 requires the initiation of a diagnostic and treatment program and the 92014 requires the initiation or continuation of a diagnostic and treatment program.

Diagnostic refers to ordering testing such as fields or OCT etc.

Treatment refers to prescribing medications or lenses, scheduling surgery, referral or patient education on eye hygiene or risk factors.

Tom Cheezum, O.D., CPC, COPC
 
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erinmccauley90 said:
I was taught that it was acceptable to code a Comprehensive Eye Exam (92004, 92014) if the following exam elements were met:
-History
-Medical Observation
-Gross Visual Fields
-Basic Sensorimotor Exam
-External/Adnexa Exam
-Ophthalmoscopic Exam (Retina/Optic Disc - vitreous, macula, vessels, periphery)
-Diagnostic/Treatment Program

I was coding encounters that met this criteria as Comprehensive visits but was then told by one of my clinicians that Medicare requires more than just these exam elements. They said that Comprehensive should only be used when there is more thought involved, when the condition has changed, etc. Their concern was that if we coded based on meeting the elements above, we would be flagged for review. I am now having a hard time differentiating between when to code an Intermediate vs Comprehensive but I can't find specific Medicare requirements anywhere. Is there more to it than just meeting the elements above?
Click to expand...
If you go to CMS 97 Guidelines and pull the Ophthalmology Specialty Coding Audit tool, it will walk you through.
 
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I guess the three main things I look at when asked to review records and determine if they are coded properly are as follows:
1) Showing medical necessity
2) Only doing what is necessary to provide the care noted in the chief complaint. I've seen some practices that have patients return basically for a medication check to determine if their glaucoma meds are controlling the IOP at the desired level but they do a comprehensive exam at level 4 codes. Is that really necessary? Not IMHO. They are just trying to do more to bill the higher code.
3) The level and complexity of MDM

Of course there are other things I look at but these are most important to me.

Tom Cheezum, OD, CPC, COPC
 
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Jadams421 said:
If you go to CMS 97 Guidelines and pull the Ophthalmology Specialty Coding Audit tool, it will walk you through.
Click to expand...

Are you referring the 97 Ophthalmology exam elements for E/M coding? Correct me if I am wrong, but I was under the impression that these exam elements pertained to the E/M codes only, not the eye codes, which exam requirements are not clearly defined anywhere? I am still relatively new to auditing, especially specialties, so please correct me. Thanks
 
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erinmccauley90 said:
I was taught that it was acceptable to code a Comprehensive Eye Exam (92004, 92014) if the following exam elements were met:
-History
-Medical Observation
-Gross Visual Fields
-Basic Sensorimotor Exam
-External/Adnexa Exam
-Ophthalmoscopic Exam (Retina/Optic Disc - vitreous, macula, vessels, periphery)
-Diagnostic/Treatment Program

I was coding encounters that met this criteria as Comprehensive visits but was then told by one of my clinicians that Medicare requires more than just these exam elements. They said that Comprehensive should only be used when there is more thought involved, when the condition has changed, etc. Their concern was that if we coded based on meeting the elements above, we would be flagged for review. I am now having a hard time differentiating between when to code an Intermediate vs Comprehensive but I can't find specific Medicare requirements anywhere. Is there more to it than just meeting the elements above?
Click to expand...

Have you tried searching the AAO site? They have information and links available to all. If one of your docs is a member and you can log in, you'll be able to do a better search. There is also the Corcoran consulting group which sells monographs for specific issues if you want.
 
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I have tried the AAO site and cannot find anything not open to non-members. While our group is probably a member, I am hesitant to ask them until I have exhausted other resources. We have also run into the question regarding what constitutes the "general medical observation" portion of the visit. One resource that one on our coders found states that this must include things like appearance, nutritional state, body features and symmetry. I found a few other resources that states this can merely be their list of meds, allergies, medical history.

Can anyone verify or provide a good resource?
 
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What you are asking about in regards to "general medical observation" isn't a part of the actual examination of the eyes. I believe that would fall under the ROS portion of the patient history and perhaps be part of the "Constitution" part of the exam where most providers would make a remark such as the following: "Patient is well nourished and alert" or something along that line.

Tom Cheezum, OD, CPC, COPC
 
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I understand that it is not part of the exam, but it is stated that it is one of the requirements to bill for the eye codes as I understand it. The EMR that these providers are using have sections for HPI, mental status, medical history, systemic meds, allergies and family and social history. We are trying to determine if this will meet a general medical observation to meet the guideline for the eye codes. Two coders here say that it doesn't due to references that they have found. I understand the exam portion of the documentation for the visit.

Please let me know your opinion
 
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The "general medical observation" is not one of the standard exam elements accepted by the majority of sources I've seen. There is a reference to this in one article as being an additional part of the exam which, if done, isn't able to be coded as an additional procedure. As I said before, this seems to be something more along the line of the "Constitutional" part of the ROS.

Tom Cheezum, OD, CPC, COPC
 
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hi I want to how to code an ophthalmology exam done under IV sedation (not general anesthesia). any help is greatly appreciated.
 
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I'm going to correct or modify some of my earlier comments about what constitutes "general medical observation" after speaking with a colleague who has done only eye care billing, coding and record keeping lecturing for over 20 years and also does audits on a regular basis.

He feels that, since a 92004 or 92014 exam is for s single organ system, the eyes, that recording of the various conditions of a patient's eyes, such as cataracts, dry eye, glaucoma etc, in the exam elements and especially in the assessment section of the exam meets the "general medical observation" requirement for these exams. It isn't something that can be addressed in the ROS.

He also pointed out that eye specialists, ODs and OMDs, are not required to comment on height, weight or BMI which is something that a PCP might comment on during a general physical exam, so those types of remarks in an eye specific exam wouldn't apply to the "general medical observation."
 
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Going off my original question of when to code Intermediate vs Established, doesn't the Intermediate CPT code also require initiation and continuation of a diagnostic/treatment program? If the following exam elements are met (History, Med Obs, Gross Visual Fields, Basic Sensorimotor Exam, External/Adnexa Exam, Ophthalmoscopic Exam) but there is no diagnostic/treatment program (no tests or anything are ordered and literally all the OD says is "follow-up with concerns"), can you still code an Intermediate?
 
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If you look in the CPT coding book, the phrase "always includes an initiation of diagnostic/treatment program" under the definition of the comprehensive exam, but not under the description for the intermediate exam. I guess we can assume that it is NOT an integral part of the intermediate exam. I have read many conflicting opinions, but am going with what the coding "bible" says.
 
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Actually, the 92002 says, "initiation of diagnostic and treatment program" and the 92012 says "initiation or continuation of diagnostic and treatment program."

Personally, I don't feel that "follow up with concerns" qualifies as an initiation or continuation of a diagnostic and treatment program without specifying what the specific concerns are and how you're going to follow up by things such as ordering tests or checking progress on a prescribed treatment.
 
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