Which procedure code should be submitted for general ophthalmological services (CPT codes 92002, 92004, 92012 and 92014) or an Evaluation and Management (E/M) code?
Answer: It depends on your documentation. Read more about how the requirements for the two code sets differ.
Documentation is Key
Whether you opt to submit a general ophthalmological services code or an E/M code, your documentation must support the code you submit.
Unlike Evaluation and Management CPT codes (99201-99215), no formal system describing required documentation (other than the specific elements delineated in the descriptions in the next section) has been established for the general ophthalmologic services codes.
General Ophthalmological Services
There are two levels of general ophthalmologic services, intermediate and comprehensive as described below. These codes are appropriate for services to new or established patients when the level of service includes several routine optometric/ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry and motor evaluation, which are integrated with and cannot be separated from the diagnostic evaluation. Itemization of individual service components is not applicable.
Common physical examination elements of an ophthalmologic examination must be documented as indicated by the issues being evaluated and include:
- Visual Acuity (does not include determination of refractive error)
- Confrontation visual fields
- Eyelids and adnexa
- Ocular motility
- Anterior Chamber
- Intraocular pressure
- Retina (vitreous, macula, periphery, and vessels)
- Optic disc
Levels of Examination
According to the CPT Assistant published by the American Medical Association (September 2008):
- Comprehensive ophthalmological services include a general evaluation of the complete visual system and may constitute a single service entity but need not be performed at one session. It includes 'history, general medical observation, external and opthalmoscopic examinations, gross visual fields, basic sensorimotor examination and, if indicated, biomiscroscopy, examination with cycloplegia or mydriasis, and tonometry as well as the initiation of diagnostic treatment programs.'
- Intermediate ophthalmological services include 'an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated, including the use of mydriasis for ophthalmoscopy'
- Eye refraction is considered a non-covered service; therefore you are not required to submit a claim to Medicare
- If the patient requires a Medicare denial for the refraction (for example, to submit to a secondary insurer), HCPCS modifier GY must be appended to CPT code 92015
- Services that require minimal optometric/ophthalmologic examination techniques are reported with the E/M CPT codes (99201 through 99499)
- The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) jointly developed the E/M Documentation Guidelines. The initial guidelines were developed in 1995. A second set of guidelines was developed in 1997. You may use either set when determining the correct E/M code to submit, but you may not 'mix and match' between both sets.
- The level of E/M code generally depends on the extent to which the key components are documented and the medical necessity of the level of service. Depending upon the code, two or three of these key components must be documented at the required “level” in order to submit a specific CPT code:
- History (including chief complaint; history of present illness; past, family, and social history; and review of systems)
- Examination (specified by the affected body area or organ system and may include other body areas/organ systems)
- Medical decision making (including number of diagnoses or management options; amount/complexity of medical records reviewed; and risk of significant complications, morbidity, and/or mortality)
- Key differences between the 1995 and 1997 E/M Documentation Guidelines include the way chronic or inactive conditions are considered, for purposes of History of Present Illness, and the specificity of requirements for the Examination component