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Intermediate vs. Comprehensive Eye Codes??

  1. Default Intermediate vs. Comprehensive Eye Codes??
    Medical Coding Books
    Hi everyone,

    I am very new to ophthalmology and have just been hired to do some chart auditing for an eye center. I have a lot to learn about the different tests, etc., but the one thing I'm having trouble with is how to differentiate between when to use an Intermediate eye code versus the Comprehensive eye code. The doctor I'm auditing now consistently uses comprehensive and I'm just not certain he should be. I have, of course, read CPT guidelines, etc., but still can not find what I need. Can anyone tell me the 'triggers' that change an intermediate to comprehensive??

    I would greatly appreciate any ideas you have!!

    Thanks in advance,


  2. #2
    A comprehensive exam is an evaluation of the "complete visual system" and it ALWAYS includes the initiation of a diagnostic treatment program. So if the eye exam is limited to just a few sections of the eye, then it would be considered an intermediate exam.

    There is a lot of guidance in the CPT book for these codes as well.

  3. Default
    Thank you so very much...that was what I was looking for! I really appreciate the response.

  4. Default
    In order for an eye exam to be comprehensive service, new or established patient, it must (1) include a certain number of exam elements, (2) some elements must be performed through dilated pupils (or very specifically documented reasons for contraindication), and (3) document the initiation of a diagnostic and/or therapeutic plan of treatment. All three components must be met or it is not a comprehensive ophthalmic exam.
    1. All the following elements:
    • Test visual acuity (Does not include determination of refractive error)
    • Gross visual field testing by confrontation
    • Test ocular motility including primary gaze alignment
    • Inspection of bulbar and palpebral conjunctivae
    • Examination of ocular adnexae including lids, lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes.
    • Examination of pupils and irises including shape, direct and consensual reaction size and
    • Slit lamp examination of the corneas including epithelium, stroma, endothelium, tear film
    • Slit lamp examination of the anterior chambers including depth, cells, and flare
    • Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
    • Measurement of intraocular pressures (except in children and patients with trauma or
    infectious disease)

    2. Ophthalmoscopic examination through dilated pupils (unless contraindicated) of
    • Optic discs including size, C/D ratio, appearance and nerve fiber layer
    • Posterior segments including retina and vessels (eg, exudates and hemorrhages)

    3. the provider must do one of the following:
    • Order new/change/discontinue eye glass prescription/ prescription medication(s)
    • Arrange for special ophthalmological diagnostic and/or treatment services
    • Request a consultation from an ophthalmic sub-specialist or specialist in another field
    • Order laboratory procedures
    • Order radiological services

    This should get you started in determining if the chart documentation on each encounter meets the comprehensive eye exams requirements
    NOVA Medical Billing

  5. Default
    John, thank you very much for the detailed explanation you gave...very, very helpful!


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