Wiki Documentation Question for Comprehensive Exam

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kmfeldman13

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Assuming all 12 elements of an annual comprehensive examination have been completed with an associated medical diagnosis, such as cataracts, does completing a refraction or updating prescription glasses qualify as implementing treatment and does it justify billing 92014? Also, assuming all 12 elements of the comprehensive exam have been completed, does ordering or completing special ophthalmological diagnostic testing (OCT, Visual Field, etc.) meet the requirements to bill 92014 if there is no further treatment? Thank you!
 
yes, prescribing medication, lenses, and arranging diagnostic services are all examples of initiation of diagnostic and treatment programs. I would check out E&M codes once you get into the special testing your documentation may qualify for an E&M that pays more.
 
In the AMA CPT 2022 book, it says special ophthalmological services includes refraction, color vision tests, etc., but says to report them separately. So is a refraction considered a special ophthalmological service? Does completing a refraction justify billing 92014 if there is NO other hospital, prescription, over-the-counter, or self-care treatment? The only treatment documented in the exam is for the patient to update their glasses. Thank you!
 
Yes, if a refraction is done you would bill 92015. Yes, prescription for glasses is enough to meet the “initiation of diagnostic and treatment program” requirement for 92014.
 
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