MAY 31, 2022
Appropriate E/M for Glaucoma Follow-up
We have an established patient with unstable glaucoma, no adverse effects from current Rx; external exam, slit lamp and optic nerve exam performed and new medication was added. Would this be 99213 or 92012?
For unstable glaucoma that requires a change in treatment plan; one stable chronic illness with exacerbation or progression would be moderate for the number of problems. Prescription drug management would be moderate for the risk of complications. The overall risk would moderate, an evaluation and management (E/M) level 4, CPT code 99214.
For stable glaucoma that requires no change in treatment plan; one stable chronic illness would be low for the number of problems. Prescription drug management would be moderate for the risk of complications. The overall risk would be the lower of the two, low or E/M level 3, CPT code 99213.