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    New E/M Rules for Office Visits, Part 3: The Medically Relevant Exam

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement, with Ravi D. Goel, MD, and Lance M. Siegel, MD, FAAO, FAAP

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    Beginning Jan. 1, 2021, satisfying the exam requirements of the Evaluation and Management (E/M) codes 99202-99215 will become much less burdensome. As with the history component, which Savvy Coder discussed in August and September, you just need to perform and docu­ment that which is medically relevant.

    Big Changes on the Way

    No more counting elements of the exam. The current E/M regulations list 12 elements of the exam. Of these, you must document one to five elements to report a problem-focused E/M code; six to eight for an expanded prob­lem-focused E/M code; nine to 12 for a detailed E/M code; and all 12 plus a mental assessment for a comprehensive E/M code. If you are audited on an E/M service that took place in 2020 in your office (i.e., not a virtual exam), auditors will count how many exam elements you documented; if the E/M service is performed in 2021, they won’t.

    Other big changes to the exam component in 2021. In summary:

    • There will be no need to report orientation, mood, and affect unless the ophthalmologist decides to do so.
    • There will be no need to dilate, unless the ophthalmologist determines dilation is medically necessary.
    • The technician’s workup may be very different than in prior years.

    Train Your Staff

    Conquering New E/M Documenta­tion Guidelines for Ophthalmology  is now available. It combines a narrated online tutorial with an accompanying workbook.

    To learn more about this coding product, visit

    For tips on getting ready for the new E/M rules, visit

    Anterior Segment Example

    In 2021, suppose a postcataract patient presents outside any global period with a complaint of decreased vision. This turns out to be due to posterior capsule opacification. What exam elements should be documented when billing for an E/M code? To confirm the need for a capsulotomy, and to rule out other causes of the impaired vision, Ravi D. Goel, MD, would document the following exam elements: Visual acuity (VA), intraocular pressure (IOP), lens, pupils, anterior chamber, and optic nerve and retina through dilated pupils. If the laser surgery is performed on the same day or within 72 hours of the exam, you should append modifier –57 to the E/M code; this modifier indicates that the exam findings justified a major surgery (one with a 90-day global period).

    Dr. Goel is a comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, New Jersey.

    Pediatric Example

    What exam elements would be med­ically relevant for pseudoesotropia? According to Lance M. Siegel MD, FAAO, FAAP, this common diagno­sis would warrant evaluation of VA (appropriate for age), a dilated exam, a sensorimotor exam, and a cyclople­gic refraction. You would not need to include IOP, visual field assessment, or—apart from a brief, cursory look—delineation of the anterior segment. How cursory? You can state that the anterior segment is within normal limits (WNL). This could be done with retinoscopy or simply by looking at the retina and seeing a clear visual axis.    

    The retinal exam and optic nerve (ON) assessment could be stated as “posterior pole grossly normal.” Since ON atrophy, hypoplasia, or retinal abnormalities (e.g., colobomas) can be seen with strabismus, you should either rule them out or note their presence.

    What other exam comments might be medically relevant? Examples in­clude adnexa for “prominent epicanthal folds.” Psychiatric and/or developmental assessment may be important, in that there is a higher risk of strabismus in children with neurologic problems. Finally, reviewing videos or cell phone pictures and determining family history of strabismus would be helpful.

    Dr. Siegel is acting clinical director of pediatric ophthalmology and adult strabismus at The Vision Center in the Children’s Hospital of Los Angeles.

    Further Reading

    New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History (August 2020, EyeNet)

    Taking the history.  Doctors share examples for cataract, cornea, glaucoma, and pediatric ophthalmology.


    New E/M Rules for Office Visits, Part 2: How to Document the Retina Exam (September 2020, EyeNet)

    Taking retina histories. Plus the nonoffice exam.


    New E/M Rules for Office Visits, Part 4: Cornea and Oculofacial Exams (November 2020, EyeNet)

    Cornea and oculafacial examples.