• How to Choose Between E&M or Eye Codes

    Ophthalmologists are fortunate to have the option of two types of office visit codes: E&M codes (992XX) and Eye visit codes (920XX). One of the most frequent questions we receive at coding@aao.org is, “Which one should I use?”

    Find out below how to make the right choice and best document the eye exam.

    Making the Choice

    Determine by the chart documentation which level of E&M and which level of Eye visit code best supports the level of work performed and bill accordingly. To help determine this, create a simple spreadsheet that lists all office-based E&M and Eye visit codes, for at least five of your top payers.

    E&M, New Patient Commercial #1 Commercial #2 Medicare
    99201 $84.70 $82.28 $42.00
    99202 $145.60 $141.44 $72.32
    99203 $211.40 $205.36 $104.79
    99204 $324.80 $315.52 $161.10
    99205 $404.60 $393.04 $201.01
    Eye Visit, New Patient
    92002 $162.40 $138.88 $80.56
    92004 $295.40 $199.77 $146.99

     

    E&M, Established Patient Commercial #1 Commercial #2 Medicare
    99211 $39.20 $38.08 $19.48
    99212 $85.40 $82.96 $42.35
    99213 $142.80 $138.72 $70.99
    99214 $210.70 $204.68 $104.87
    99215 $282.10 $274.04 $140.57
    Eye Visit, Established Patient
    92012 $170.10 $128.34 $84.41
    92014 $246.40 $198.22 $122.40


    But it might not always be that simple. Some commercial payers also limit how frequently you can bill for Eye visit codes.

    When using E&M codes, all payers let you bill these codes as often as medically necessary. In addition, payers allow unrestricted diagnosis coverage. With Eye visit codes, you can only bill for a diagnosis if it includes ocular manifestations, with the exception of diabetes. If the condition does not have an ocular manifestation, you should use the E&M code.

    Medicare Part B doesn’t limit frequency for Eye visit codes either; this, includes comprehensive exams.

    Commercial payers often limit how often you can submit Eye visit codes and what type of diagnosis codes you can use. In many cases of systemic disease, you’ll need to bill using only E&M codes.

    How to Determine the Level of Service

    The chief complaint behind the exam determines what elements of the exam are necessary to perform and will also help determine the level of service. With the exception of 99204, 99205 and 99215, Medicare tends to have a higher allowable for Eye visit codes. For example, if you submit the exam with CPT code 99213 instead of 92012, you will collect $13 less, depending upon your geographic region.   

    Eye visit codes - comprehensive

    To determine whether a service is an intermediate or comprehensive Eye visit code, you should first factor in the number of exam elements you performed.  

    These exam elements include:

    1. Visual acuity;
    2. Gross visual fields;
    3. Extraocular motility;
    4. Conjunctiva;
    5. Ocular adnexa;
    6. Pupils and iris;
    7. Cornea, using a slit lamp;
    8. Anterior chamber, using a slit lamp;
    9. Lens;
    10. Intraocular pressure;
    11. Optic nerve discs;
    12. Retina and vessels; dilated unless contraindicated and documented in chart.

    In addition, you need to document Initiation of diagnostic and treatment program. However, to document “initiation of diagnostic and treatment program,” you must have at least one of the following:

    • Prescription of medication (or glasses);
    • Arrangement of special ophthalmological diagnostic or treatment services;
    • Consultations;
    • Laboratory procedures; or
    • Radiological procedures.

    Eye visit codes - intermediate

    An intermediate exam consists of less than 12 elements; a comprehensive exam consists of 12. If you have performed less than two exam elements, use level of service 99212.

    The intermediate exam Eye visit codes (92002 and 92012) require documentation of:

    1. Chief complaint
    2. History
    3. General medical observation
    4. Visual acuity
    5. External ocular exam
    6. Adnexal exam

    You may also dilate in the intermediate exam when necessary.  

    E&M codes - comprehensive exam component

    With E&M codes, you have five levels of exam. To bill for the comprehensive exam component as, you need to complete all 12 elements listed above and note the patient’s orientation, mood and affect.

    Do not apply the E&M audit tool to the Eye visit code; it does not apply. Instead, follow the CPT guidelines; however, always check with your payer and their conditions of use.  

    Resources

    For a more in-depth look at using Eye visit codes, check out the Academy’s e-learning course, Eye Visit Code Documentation Guidelines.

    For E&M codes, refer to the Academy’s E&M Internal Chart Auditor for Ophthalmology

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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.