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Savvy Coder: Coding & Reimbursement
E&M or Eye Codes?
How to Choose Which to Use
 
 

By Sue Vicchrilli, COT, OCS, Academy Coding Executive

Ophthalmologists have two types of office visit codes from which to choose: Evaluation & Management codes (99XXX) and Eye Codes (92XXX). For E&M codes, documentation guidelines are standardized and recognized nationally by all payers; for Eye Codes, you must consult your state Medicare Local Carrier Determination (LCD) policy. To read these policies—formerly known as Local Medical Review Policies (LMRPs)—go to www.aao.org/aaoe, select “Coding & Reimbursement” and then “Free Content” for a list of state Medicare carrier Web sites.

Making the Choice
How do you decide whether to use an E&M code or an Eye Code?

First, consider the patient’s insurer: Are you dealing with Medicare, Medicaid or some other federal payer, or an HMO or PPO with its own documentation requirements?

Second, consider the documentation in the chart: What level of E&M service does it meet? What level of Eye Code service does it meet?

Third, if your documentation meets the requirements for both an Eye Code and its E&M counterpart to the same degree, you can use the one that has the highest allowable. To take advantage of this, make sure you have the fee schedules for at least your top five payers.

You should develop your preprinted office visit form to comply with all payer requirements. Note that some payers require use of Eye Codes for refractive exams and E&M codes for medical diagnosis. Also, some payers may down-code from 92004 and 92014 to 92002 and 92012 if your documentation does not include “initiation of diagnostic and treatment program.”

Documenting the Eye Exam
Most Medicare payers have an LCD policy that will define your documentation requirements. The following documentation requirements are for all Medicare payers that lack an LCD policy, as well as most non-Medicare payers.

The intermediate examination Eye Codes (92002 and 92012) require documentation of:

  • chief complaint
  • history
  • general medical observation
  • visual acuity
  • external ocular exam
  • adnexal exam

Mydriasis may also be included in the intermediate examination.

The comprehensive examination Eye Codes (92004 and 92014) require documentation of:

  • chief complaint
  • history
  • general medical observation
  • evaluation of the complete visual system
  • visual acuity
  • external ocular exam
  • gross visual fields
  • basic sensorimotor exam
  • tonometry
  • fundus exam
  • initiation of diagnostic and treatment program, for which you must have at least one of the following:

(a) prescription of medication
(b) arranging for special ophthalmological diagnostic or treatment services
(c) consultations
(d) laboratory procedures
(e) radiological services

Covered Diagnosis Codes
What diagnosis codes can you use for Eye Codes 92002, 92004, 92012 and 92014? For a list of diagnosis codes that are probably covered, go to www.aao.org/aaoe, click through “Coding & Reimbursement,” then “Free Content” and “ICD-9’s for Eye Codes.” Of course, coverage can vary per payer.

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Typical Medicare Local Carrier Determination Policy


The 11 physician examination elements of an ophthalmologic examination are:

  • confrontation visual fields
  • eyelids and adnexa, including conjunctiva
  • ocular mobility
  • pupils/iris
  • cornea
  • anterior chamber
  • lens
  • IOP
  • retina (vitreous, macula, periphery and vessels)
  • optic disc
  • visual acuity

A comprehensive examination consists of eight or more of the elements listed above and frequently includes a fundus examination often with the pupils dilated.

An intermediate examination consists of seven or fewer of the specified elements. Services that require minimal optometric/ophthalmologic examination techniques are included in the E&M codes (99201–99799).

Initiation of diagnostic and treatment program includes the prescription of medication, lenses or other therapy or arranging for special ophthalmological, diagnostic or treatment services, consultation, laboratory procedures and radiological services, as may be indicated.

Other procedures—which may be included as part of intermediate or comprehensive ophthalmologic services and may be neither reported separately nor billed—are:

  • laser interferometry
  • potential acuity meter
  • keratometry
  • exophthalmometry
  • transillumination
  • corneal sensation
  • tear film adequacy
  • Schirmer test
  • slit lamp
  • history commensurate with the definition of “intermediate”
  • general medical observation