Many types of audits target comprehensive Eye visit codes. These five tips will help you and your coding support team stay on top of the latest documentation requirements.
#1 Know when to use comprehensive exam codes 92004 and 92014
- 92004 — Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
- 92014 — Ophthalmological services; medical examination and evaluation with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
The CPT description states the following: “Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It always includes initiation of diagnostic and treatment programs.”
For help choosing between E&M or Eye codes, review YO Info’s updated guide.
#2 Complete all required elements
To bill for a comprehensive exam, you must perform all 12 elements, unless contraindicated or prevented by patient age or trauma. If one of these factors keeps you from performing an element, you should document it in the chart.
The 12 elements match those identified in E&M requirements:
- Visual acuity;
- Gross visual fields;
- Extraocular motility;
- Conjunctiva;
- Ocular adnexa;
- Pupil and iris;
- Cornea;
- Anterior chamber;
- Lens;
- Intraocular pressure;
- Optic nerve discs;
- Retina and vessels.
#3 Follow the right set of documentation requirements
The Eye visit codes were developed long before the 1995 E&M documentation requirements. You do not need to document time, place, person and/or mood and affect when billing Eye visit codes. You do need to document these if billing a comprehensive E&M visit code.
As a reminder, to be a comprehensive E&M exam, you must perform all 12 elements of the exam and document time, place, person and/or mood and affect. Otherwise the E&M exam is detailed, not comprehensive.)
#4 Dilate or document why you don’t
According to CPT language, “[The comprehensive exam] often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry.” However, auditors automatically look for an indication of dilation. If you don’t dilate, indicate why not.
#5 Meet the post-exam requirements
Billing an Eye visit comprehensive exam also requires you to initiate or continue a diagnostic and treatment program. According to CPT language, initiation of the program includes “the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.”
For a more in-depth look at Eye visit codes, check out these Academy coding resources:
If you have additional coding questions, email coding@aao.org.
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.