routine vs medical, ophthalmology

Messages
15
Location
Union, MO
Best answers
0
If the Ophthalmologist sees a Pt and only lists DMII and HTN on superbill; is that considered a medical visit as it would w/ an E&M visit? OR is it considered a routine visit because no manifestations are diagnosed?
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
Messages
2,113
Location
South Berwick, ME
Best answers
0
When you say 'routine', do you mean 'preventive'? Those are coded with V-codes, specific to the type of examination.

I would question medical necessity with the DM and HTN codes as provided by the opthamologist....is he treating the DM and HTN? I doubt it....he's likely treating eye conditions related to these underlying diseases. Maybe you can provide him with a more appropriate diagnosis code as would be related to eye care and the reason the patient presented to the office, even if it's a symptom only.

Also, your diagnosis won't entirely determine the kind of visit; that is determined based on the intent of the visit as well as the documentation provided. E&M visits have key components that need to be documented, and there are codes in the medicine section of CPT specifically for opthalmologic care.
 
Messages
64
Location
Denver
Best answers
0
Ophthalmologists do routine follow-ups for diabetes each year looking for retinopathy. Eye codes can be used for these follow-ups. Make sure your exam elements are met. We use full SLT for intermediate codes 92002/92012 and Confrontational Visual Fields,Ocular Motility, full SLT and dilated Fundus exam for comprehensive codes 92004/92014. Also make sure you meet the criteria for initiating diagnostics/treatment for the comprehensive codes. There is some controversy as to whether to use the intermediate codes for yearly follow-ups: If a doc does a full exam yearly and lists: IDDM -no significant retinopathy and does not do any diagnostics/treatment (eyedrops for dry eyes/antibiotics/laser/OCT, Fundus photos,FA, etc) I code it with a 92002 for new pts and a 92012 for established pts. Riva Lee Asbell agrees with this. If the exam elements are not met, then you have to go with E/M codes, which follow set rules. Remember, the chief complaint written properly: "diabetic check for retinopathy/follow-up check on previous retinopathy treatment", etc) gives you the medical necessity.
 

dhvoyles

Contributor
Messages
13
Best answers
0
If it turns out that your chief complaint really is just DM, there are many medical plans that do provide coverage for an annual eye exam for the diabetic patient with no ophthalmic manifestations, even though the plan specifically excludes routine vision care. So it's possible that your superbill is correct, and it's appropriate to file a medical claim using either E/M or the eye codes, depending on your documentation, as the other responders pointed out. Which code set to use might depend on the payer.
 
Top