• The Eye Exam: Don’t Be Baffled by These Billing Brainteasers

    By Sue Vicchrilli, COT, OCS, Academy Coding Executive 

    This article is from March 2009 and may contain outdated material.

    For the typical ophthalmologist, the exam is the bread and butter of the practice. By reviewing this quick quiz, you can avoid some common errors made when coding exams.

    Test Your Knowledge

    1. An optometrist, who is employed by an ophthalmologist, sees a new patient. He then refers her to that ophthalmologist. Can they both bill for a new patient (codes 92004 and 99204) provided they see her on different days?

    2. Is there a specific Medicare form that patients must complete to establish financial hardship?

    3. Do codes 92004, 92014, 99204, 99205, 99244 and 99245 require dilation?

    4. A pediatrician sends a patient to an ophthalmologist to rule out a medical problem, such as amblyopia. The Eye M.D. does not find a medical problem and concludes the exam is a normal one. What is the proper way to code for this rule-out?

    5. A patient came in because she has a family history of glaucoma and wanted a pressure check. There was no sign of glaucoma. The practice coded 92004 with V19.1. The insurance company paid toward the visual fields but denied 92004, and then told the patient that the practice had used the wrong code. The practice plans to resubmit the claim. What is its most effective code choice?

    6. A general ophthalmologist diagnoses a patient with a condition that he does not normally treat. The patient is referred to a retina physician who evaluates the problem and schedules surgery. The general ophthalmologist is transferring care of the “specific problem,” not transferring complete care. Would it be appropriate for the retina physician to code this as a consultation?

    7. A practice occasionally performs intraoffice consults. Is it sufficient to have one physician read the other physician’s chart note and sign?

    8. How often should patients fill out new paperwork for the review of systems (ROS) and pertinent past, family and/or social history (PFSH)? Is it annually?


    1. Once the patient is seen by either the practice’s ophthalmologist or optometrist, subsequent visits to see anyone in the practice should be coded as established patient visits.

    2. Since Medicare has no such form nor published criteria, offices take several different approaches. Some, for instance, simply take the patient’s word, others request tax returns and others have developed their own, in-house form. (The AAOE’s Practice Forms Master, available at www.aao.org/store, includes many examples of in-house forms.)

    3. Unless contraindicated, dilation is required for 92004, 92014, 99204, 99205, 99244 and 99245.

    4. The good news: The eyes are healthy. The bad news: Unless the patient has a vision plan, the exam may not be covered. There are no true rule-out diagnosis codes.

    5. The denial probably has to do with her coverage policy. When patients have a vision plan, the insurer expects medical diagnosis codes to be billed with a code for an E&M exam (99XXX), not an Eye Code (92XXX). Resubmitting with the appropriate level of 99XXX code is the best choice.

    6. The consultation clarification language states that the transfer is for that condition. Rather than code a consultation, it would be best for the retina doctor to code the appropriate level of E&M or Eye Code for a new or established patient.

    7. No. When coding a consult, the additional money is for producing communication to the requesting source. Many payers will allow a summary paragraph in lieu of a letter.

    8. While the ROS and PFSH may be reviewed and updated at each encounter, complete new paperwork should be obtained only if the patient is “new,” or if it has been three years since the patient has seen anyone in the practice, or if the rules should change.