Wiki New to Optometry coding and billing. Help!

[thescientist8]

The Dr. put down, 92004, 92225, 92015. is this correct? what tests can be done to code a 92225?

Chief Complaints:
1. LS: Low Vision.

HPI:
History:
Eye Diagnosis _ presbyopia Cataracts, ho pituitary tumor followed at Jacobi hospital last vf 1/18.
LEE 5 years jgb.
NEE _, 1 year.
Referred by _self.
Ocular Symptoms _ no pain, BIRT no flashes or floaters.
Certified LB? _ NO.
Certified Legally Blind/Counselor _.

Medical History: Type 2 diabetes x 1980 diet controlled fbs 97 last week, Migraine, Obesity, Osteoarthritis, Thyroid removed x 2 years, Pituitary tumorx 2 years.


Family History:
no family history of eye disease.

Social History:
Tobacco Use:
Tobacco Use/Smoking
Are you a current smoker
Drugs/Alcohol:
Alcohol Screen
Points 1
Interpretation Negative

Medications: Taking Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution 2 puffs as needed Inhalation every 4 hrs, Taking Aspir-81 81 MG Tablet Delayed Release 1 tablet Orally Once a day, Taking Lisinopril 20 MG Tablet 1 tablet Orally Once a day, Taking Metoprolol Tartrate 25 MG Tablet 1 tablet Orally Twice a day, Taking Prilosec 20 MG Capsule Delayed Release 1 capsule Orally Once a day, Taking Simvastatin 20 MG Tablet 1 tablet in the evening Orally Once a day, Taking Cabergoline 0.5 MG Tablet 1 tablet Orally , Taking Levothyroxine Sodium 100 MCG Tablet 1 tablet on an empty stomach in the morning Orally Once a day, Medication List reviewed and reconciled with the patient

Allergies: N.K.D.A.


Objective:

Vision Examination:
Auto Refraction
Sph Cyl Axis Add DVA NVA
OD +2.00 -2.00 86
OS +1.75 -0.50 46

Spectacle
Presenting
Sph Cyl Axis H Prism V Prism Add DVA NVA PH
OD +2.25 -0.50 90 +2.50 20/40 20/30
OS +2.25 +2.50 20/40 20/30
OU 20/20 20/30

Final
Sph Cyl Axis H Prism V Prism Add DVA NVA PH
OD +2.25 -1.25 85 +3.00 20/30 20/30
OS +2.00 -0.50 80 +3.00 20/30 20/30
OU 20/30




Examination:
Ophthalmology:
PUPILS ___ PERRL(-)APD 4mm OU (both eyes).
EXTRAOCULAR MOVEMENT ___ full, smooth, commitant OU (both eyes).
COVER TEST ___.
CONFRONTATION VISUAL FIELD (CVF): ___ full to finger counting OU (both eyes).
AMSLER GRID ___.
LOW VISION SPECTACLES ___.
AOLITE SPECTACLES ___.
POWERMAG HAND MAGNIFIERS ___.
ESCHENBACH HAND MAGNIFIERS ___.
POWERMAG STAND MAGNIFIERS ___.
ESCHENBACH STAND MAGNIFIER ___.
TELESCOPES ___.
SUNWEAR EVAL ___.
CCTV ___.
LIGHTING ___.
HAND MAGNIFIERS _____.
STAND MAGNIFIERS ___.
COIL HAND MAGNIFIERS ___.
COIL STAND MAGNIFIERS ___.
ADNEXAE: ___ clear OU.
CORNEA: ___ clear OU.
CONJUNCTIVA: ___ clear OU.
IRIS: ___ clear OU.
ANGLES ___ D&Q OU 3x3 OU.
LENS: ___ nuclear sclerosis Grade 2 OU (both eyes).
VITREOUS: ___.
TBUT ___.
UNDILATED FUNDUS EXAM ____ CD ratio: 0.4/0.4 A/V 1/3 OU Macula: clear OU.
DILATED EYE EXAMINATION _____ one gtt 1%T,one gtt 2.5% PE CD ratio 0.4/0.4 OU A/V ratio 1/3 OU Macula sharp, distinct Peripheral retinal no tears, holes 360 degrees to extent seen OU.
INTRAOCULAR PRESSURE (IOP):
Right Eye 16
Left Eye 14
time 12.02



Assessment:

Assessment:
1. Presbyopia - H52.4 (Primary)
2. Age-related nuclear cataract of both eyes - H25.13
h/o pituitary tumor, being followed at Jacobi hospital every 6 months for VF.

Plan:

1. Age-related nuclear cataract of both eyes
Notes: Patient Educated with: Care of eye diseases.pdf (Care of eye diseases.pdf).

2. Others
Notes: order new bifocal rx thru metroplus, continue jacobi to monitor pit tumor, if no improvement with glasses consider cat xt.


Procedure Codes: 92015 REFRACTION, 92225 SPECIAL EYE EXAM, INITIAL

Preventive:
Screening/Special Tests:
CQM Exceptions
BMI not calculated Patient refused to record height/Weight
Immunizations:
Influenza
Have you had a flu shot since the most recent September 1? Yes

Follow Up: will call when devices or glasses arrive (Reason: dispense with optician)

 

[Cheezum51]

I'm looking at what you've submitted as an optometrist who has been in practice for 40 years. Here are things I find wrong with what your doctor has done here:

1) There is nothing in the exam or diagnosis that justifies the CC of "low vision". There's a huge difference between blurred vision and low vision.

2) The diagnosis of cataracts does not qualify as low vision. Also, that diagnosis doesn't justify the 92225 extended ophthalmoscopy nor does the fact that the patient is diabetic especially since there's no mention of diabetic retinopathy. Also, your doctor hasn't done what's necessary to bill the 92225 code. It requires that there be a significant retinal problem which requires additional examination efforts above and beyond what is shown in the record. The 92225 also requires a separate interpretation and report and a drawing of at least 3 inches by 3 inches in size, The I&R should tell what examination lens or lenses were used and wether scleral depression was used along with a written description of the retinal abnormality noted.

If I audited this record, and if your doctor is using the 92225 code frequently without diagnostic justification to support its need, you would fail the audit and owe money to the carrier.

A suggestion, if you step up your history, especially HPI and PFSH and do one more exam element and a note is made in the exam portion about the patient mood and orientation to person place and time, you could bill a 99204 which probably pays about $30 more than the 92004.

Sorry if I sound harsh, but I see my optometric colleagues making these types of mistakes all the time and they are setting themselves up for audit failure.

Tom Cheezum, O.D., CPC, COPC

 

[thescientist8]

Thank you so much! I really appreciate this. I knew there was something wrong.

I'm currently working on denials and I've been seeing a lot of 92225, and the notes don't even support it.

Anyway, thanks again. this is helpful!

 

[Cheezum51]

You're welcome. Unfortunately, I see many ODs who have no idea of what is required to bill the 92225 code properly.
If you're looking at the patient records and not seeing any of the reporting and drawing requirements that I noted in my first response, then you need to do one of two things.

1) If you weren't paid for that code, don't appeal the decision.

2) If you have been paid for the code and the records don't meet the criteria for recording it, you may want to consider having your doctor send that money back to the insurance company.

Tom Cheezum, O.D., CPC, COPC