• E&M or Eye Code: Which to Choose?

    Ophthalmology is fortunate to have two choices when it comes to the code selection of an office exam — E&M codes (99XXX) and Eye codes (92XXX). So how do you determine which of the two is the best selection?

    Gather data ahead of time and your practice can quickly choose the most appropriate code after you’ve decided the level of service. The most efficient practices know what each insurance carrier’s fee schedule will be for the year.

    Confirm your top payers, and create a spreadsheet outlining both E&M and Eye codes with the allowable amounts of each payer. This way you can compare the two and take advantage of your options.

    “This one change in process — which we implemented after attending a CODEquest seminar — had a very significant impact on practice revenues,” said Robert E. Wiggins Jr., MD, the Academy’s senior secretary for ophthalmic practice. He’s the managing partner of a group practice in North Carolina.

    Here’s an example of such a spreadsheet:

    CPT Commercial Payer #1
    Commercial Payer #2
    New Patient
    99202 $145.60 $141.44 $73.32
    99203 $211.40 $205.36 $104.79
    99204 $324.80 $315.52 $161.10
    99205 $404.60 $393.04 $201.01
    New Code
    New Patient
    92002 $162.40 $138.88 $80.56
    92004 $295.40 $199.77 $146.99


    CPT Commercial Payer #1
    Commercial Payer #2
    99212 $85.40 $82.96 $42.35
    99213 $142.80 $132.72 $70.99
    99214 $210.70 $204.68 $104.87
    99215 $282.10 $274.04 $140.57
    Eye Code
    92012 $140.10 $128.34 $84.41
    92014 $206.40 $198.22 $122.40 

    Test Your Knowledge

    Case #1: Insurance type — traditional Medicare. A 66-year-old woman is referred with a history of migraines, cystitis and Sjögren’s disease. She has recently noticed vision loss in her left eye (OS) with blurry vision upon waking. 

    Review of systems (ROS): 10 systems
    Past, family and social history (PFSH): All three reviewed
    Exam: 13 elements

    Diagnosis: Migraine, visual disturbances, Sjögren’s syndrome, macular scar OS
    Plan: Refer to a retina specialist; return in one year or as needed

    E&M code: 99203
    Eye code: 92004

    In this example, you should submit Eye code 92004, because Medicare reimburses at a higher rate for Eye codes than E&M codes. This is due to multiple factors, including practice expense. The slit lamp is considerably more expensive than the stethoscope. However, there are two exceptions: E&M code 99204 will reimburse higher than 92004, and E&M code 99215 will reimburse higher than 92014. 

    Case #2: Insurance type — commercial payer #2. A 55-year-old male returns for follow-up for mild nonproliferative diabetic retinopathy. His vision is good, and blood sugar is under control and remaining stable.

    ROS: Eyes
    PFSH: No changes in medication
    Exam: 12 elements, including dilation

    Diagnosis: Mild nonproliferative diabetic retinopathy
    Plan: Recheck in six months

    E&M code: 99213
    Eye code: 92012

    Most non-Medicare payers have higher allowables for E&M codes. In this example, our commercial payer allowable is higher for the E&M code than the Eye code, so you would bill 99213. 

    Diagnosis Can Affect Code

    Have staff clearly indicate in the documentation why the patient presented for the examination; this can affect code selection. For example, if a patient presents for a vision examination, an Eye code is the clear choice due to the chief complaint and the diagnosis. Remember, Medicare Part B does not cover these types of services, so the patient may be responsible for the payment.

    Note that commercial payers may require you to bill a vision diagnosis when submitting an Eye code. If billed with a medical diagnosis, the patient may inadvertently become responsible for payment. These payers may also have frequency edits pertaining to Eye codes.

    It is always best to check with each payer to confirm what is required — after all, as Dr. Wiggins reminds us, “In an era of declining reimbursement and increasing practice expenses, accurate coding is more important than ever.”

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    About the author: 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 Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series. Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She oversees the Academy’s Chart Auditing Service and is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.