You are about to submit a claim for an eye exam.
Question: Should you submit the service using the appropriate code 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
- Your documentation must meet or exceed the requirements for submitting the code
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.
The physical examination elements of an ophthalmologic examination are 10 in number and include:
- Confrontation visual fields
- Eyelids and adnexa
- Ocular mobility
- Pupils/iris
- Cornea
- Anterior Chamber
- Lens
- Intraocular pressure
- Retina (vitreous, macula, periphery, and vessels)
- Optic disc
Levels of Examination
- A comprehensive examination consists of eight or more elements, and always includes a fundus examination with the pupils dilated
- An intermediate examination consists of seven or fewer of the specified elements
Eye Refraction
- When submitting claims for denial purposes, correction of refractive errors should be submitted using CPT code 92015. There should not be an additional evaluation and management charge. No payment will be made for CPT code 92015 and an E/M code.
- If the patient does not need a Medicare denial for refraction (for example, to submit to a secondary insurer), you are not required to submit claims for eye refraction. Eye refraction is always non-covered.
E/M Services
- Services that require minimal optometric/ophthalmologic examination techniques are reported with the E/M CPT codes (99201 through 99799)
- 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 system and may include other body areas/systems)
- Medical decision making (including number of diagnoses or management options; amount/complexity of medical records, diagnostic tests, and/or other information that must be analyzed; risk of significant complications, morbidity, and/or mortality; comorbidities; associated with the presenting problem, diagnostic procedure, and/or possible management options)
- 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
Reference
- The "CPT Assistant", January 2007, Volume 17, Issue 1 contains a related Q&A on this topic
- Take advantage of free training offered by Palmetto GBA clinical education staff to learn more about how to understand and apply the E/M Documentation Guidelines. To view a list of upcoming workshops or to download E/M educational guides, by going to the home page for Ohio, South Carolina Part B or West Virginia. Select Learning and Education and then Workshop handouts.
- Conduct internal audits of documentation vs. code selections
- Consider using a standardized 'scoring tool' for consistency in applying the E/M Documentation Guidelines. Palmetto GBA publishes one such tool on our Web site, although there are many others from which to choose.
- Refer to the E/M Help Center on the Palmetto GBA Web site:
last updated on 07/01/2009