• Eye or E&M Code? That Is the Question

    Ophthalmologists have two types of office visit codes to choose from: Eye codes (92XXX) and E&M codes (99XXX). What are their similarities and differences? YO Info breaks them down.

    What They Have in Common

    General principles. The documentation requirement for each code set varies, but they both share the same general principles.

    Medical record documentation is required to record pertinent facts, findings and observations about the patient’s health history, examinations, tests, treatments and outcomes. An appropriately documented medical record can reduce many of the “hassles” associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

    New vs. established patient. New versus established patient guidelines are the same for both Eye and E&M codes. A new patient is defined as one who, within the previous three years, has not received professional services from a physician or another physician of the same specialty belonging to the same group practice. Established patients are defined as receiving professional services within that three-year period.

    E&M consultation codes still exist. However, as the years go by, payers are using them less and less. For most payers, office-based consultations should now be coded with the appropriate level of new or established patient E&M or Eye code, and inpatient consultations should be coded with the initial hospital visit (99221–99223).

    Any physician seeing a patient registered in the emergency department may use emergency room visit codes (99281–99288). It is not required that the physician be assigned to the emergency department. Be sure to use place of service (POS) 23 for these visits.

    For a complete set of all E&M codes, consult your CPT book.

    Signature requirements. Eye and E&M codes also share a signature requirement. An identifiable signature is an essential part of chart documentation.

    What about an identifiable signature for paper charts? A legible full signature, a legible first initial and last name and a signature above the typed name all qualify. Remember that stamped signatures or handwritten physician names from staff are unacceptable.

    What if I have an electronic medical record system? The thing to remember about electronic medical records is that your electronic signature must be authenticated and safe guarded against misuse or modification. It should be easily identifiable as an electronic signature, and the physician’s password must be secure. As the physician, you bear the responsibility of the authenticity of the information, whether it is paper or electronic.

    What Sets the Codes Apart

    1. Documentation is standardized and nationally recognized by all payers for E&M codes, whereas documentation for Eye codes may vary by state and payer.
    2. There are no frequency edits for E&M codes; however, for Eye codes, there are edits for non-Medicare payers. Typically, CPT 92014 Ophthalmological service, comprehensive, established patient is covered once within a 12-month period. Medicare does not have this edit.
    3. Unrestricted diagnosis coverage exists for E&M codes, but Eye codes include limited lists of covered diagnosis codes that vary by payer.
    4. There is an official audit form for E&M codes, but none for Eye codes.
    5. Medical exams are typically reported with E&M codes, whereas vision exams are reported with Eye codes, depending on payer rules.

    How Do I Decide Which to Use?

    Keep in mind these five elements when choosing between codes:

    1. Pay attention to the patient’s insurance documentation requirements.
    2. Look at the documentation, and ask yourself what level of E&M code and what level of Eye code it meets.
    3. In the event that two codes meet the criteria to the same degree, consider billing the code (E&M or Eye) that has the highest allowable.
    4. Most non-Medicare payers require a medical diagnosis for E&M codes and a refractive diagnosis for Eye codes.
    5. Determine prior to beginning the exam whether the patient wants a vision or medical exam, as defined by their chief complaint. Many patients have coverage for both.

    A Parting Thought

    If two exams were performed in the same day with two physicians in the same group, what do you do? The rule is that only one E&M service may be reported, unless the exams are for unrelated problems. Payers do not recognize subspecialists.

    Want to Learn More?

    If you found this helpful, join us at the Annual Meeting for “When to Use E&M and When to Use Eye Codes” (event code 307) on Sunday, Nov. 17, from 2 p.m. to 4:15 p.m. This course will further help you distinguish the difference between the two code sets and determine when it is appropriate to use one over the other.

    Visit the American Academy of Ophthalmic Executives’ website for more information and a full list of course offerings.

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    About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.