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E/m Versus Eye Codes


Nashville, Tennessee
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Okay Gang I Need Your Help Please Explain More About The E/m Codes Vs The Eye Codes. Some Of The Insurance Companies Are Having Some Qualms About This. ....how Can I Explain When To Use What. I Have Not Been Able To Go To Any Of The Seminars To Really Get A Good Grip On This. The Insurance Companies Are Saying That The Eye Codes Are For Eye Exams But When I Look In The Cpt Manual These Are For Medical Diagnosis Not Routine Vision. Thanks Everyone Who Helps.


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E/M vs Eye Codes

It's basically up to the doc. Typically, the E/M codes are problem visits, with definite documentation guidelines, including, but not mandatory, the single organ system exam from the '97 guidelines.
The eye codes have less demanding documentation requirements, eg. no chief complaint, HPI, ROS or PFSH, although they do require recording a history. These codes can be used for problems also, "new diagnostic condition or management problem".
Each set has criteria that must be met and you can find that in CPT.
Best answers
E/M Vs. Eye Codes

I use 92004, 92014, 92002, 92012 for Eye Examinations and base my code selection on Medicare and Medicaid guidelines for each.

The Medicaid provider manual on emedny.org spells out pretty clearly when to use each code and what medicaid considers to be a complete optometric exam. There needs to be a case history, internal and external eye exam, objective and subjective determination of refractive state, binocular coordination testing, gross visual field and tonometry for recipients age 35 and over and routine opthalmoscopy and controntational testing for visual assessment. If these requirements are not met, I use an E/M code.


By Medicare standards, there are 11 elements of an opthalmologic exam: test visual acuity, gross visual fields, eyelids and adnexa, ocular mobility, pupils/iris, cornea, anterior chamber, lens, intraocular pressure, retina, and optic disc. Intermediate and comprehensive exam codes require evaluation of eight or more elements.

For 92002-92012 you need eight elements plus a history, general medical observation, and external ocular and adnexal exam.

For 92004-92014 you need eight elements plus history, general medical observation, external and opthalmoscopic exam, gross visual field and basic sensorimotor exam. It often includes biomocroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of a diagnostic treatment program.