By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
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Which two exam codes do you bill most frequently? The odds are that they would be the Eye visit codes for a new (92004) and established (92014) patient.
Keep this checklist handy. It will be a valuable reference for both billers and compliance departments.
Being audited? Auditors have been known to incorrectly apply the documentation guidelines for E/M codes to Eye visit codes, so make sure that the auditor has a copy of this checklist.
Defining the Codes
CMS published these two definitions.
92004: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.
92014: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
What is a comprehensive exam and evaluation? In brief, it is a general evaluation of the complete visual system. To bill for a comprehensive Eye visit code, you also must initiate or continue a diagnostic and/or treatment plan (see checklist below).
Comprehensive or intermediate exam? The comprehensive Eye visit codes (92004 and 92014) require all 12 elements of the examination (see checklist below), whereas you can submit the intermediate codes (92002 and 92012) if you’ve performed at least three, but fewer than 12, of them.
Comprehensive Eye Visit Code Checklist
Use this checklist for CPT codes 92004 and 92014.
History
☐ Chief complaint
☐ History
☐ General medical observation
Examination
Perform—and document—all 12 elements of the exam, unless patient age or trauma prevents you from doing so (in which case, document the reason).
☐ Visual acuity
☐ Gross or confrontation visual fields
☐ Extraocular motility
☐ Conjunctiva
☐ Ocular adnexa
☐ Pupil and iris
☐ Cornea
☐ Anterior chamber
☐ Lens
☐ Intraocular pressure
☐ Optic nerve discs
☐ Retina and vessels
☐ Dilation: As medically necessary. If not dilated, document why.
Initiation of Diagnostic and Treatment Program
Actions that could satisfy the codes’ postexam requirements include, but are not limited to, the following:
☐ Prescription of medication, glasses, or contact lenses
☐ Arranging for special ophthalmological diagnostic or treatment services
☐ Consultations
☐ Laboratory procedures
☐ Radiology services
☐ Recommendation or decision for or scheduling or performance of a major (90-day global period) or minor (0- or 10-day global period) surgical procedure.
☐ Scheduling necessary follow-up of a medical problem
☐ Other:
Get More Coding Help
The AAOE has developed an extensive range of coding products (aao.org/codingtools), and its experts are touring the country with Codequest, which is a half-day coding boot camp (aao.org/codequest). AAOE members can also use the Online Ophthalmology Community to crowdsource answers to their coding conundrums (aao.org/practice-management/aaoe-talk-overview).