Eye Exam 92xxx versus EM 99xxx
CS Eye, Compliance Specialists Inc., maintains that the final determination on billing eye examination codes (92002-92014) or evaluation and management codes (99201-99215) lies with the eye care professional (Ophthalmologist or Optometrist) performing the service. This determination should be based on the patient’s presenting problem and the service performed and documented by the eye care professional.
CS Eye, Compliance Specialists, Inc., recognizes that this can be an area of confusion and has compiled the following information to be used as a guide in determining the appropriate level of service.
The AMA was asked to define the difference between Eye Codes and Evaluation and Management codes. In CPT assistance September 2008 they responded that either set of codes may be used for an eye examination.
E&M codes require documentation of history, examination and decision making
Eye examination codes include history, general medical observation, external ocular and adnexal examination, and as indicated, ophthalmoscopy, biomicroscopy, tonometry
Refractive services are billed separately for both E&M codes and eye examination codes
Eye examination codes always include the initiation of diagnostic and treatment programs. According to the AMA (published in CPT Assistant January 2011) the initiation of diagnostic and treatment program include the prescription of medication and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological procedures.
There are various interpretations as to if the initiation of treatment includes prescriptions for refractive errors, however many payers look for codes 92002-92014 to be submitted for routine eye examinations. Remember Medicare does not pay for a routine eye service if the patient presents with no signs, symptoms or complaints.
As general guidance:
If the service primarily focuses on eye function, bill codes 92002-92014
If refraction (92015) is performed to determine the need to prescription lenses, bill codes 92002-92014
If the ROS and PFSH were considered not necessary elements in the course of gathering information on the presenting problem, bill codes 92004-92014
If the patient presents with signs, symptoms or complaints indicative of a medical problem, bill code 99201-99215
If the patient presents for follow-up of a diagnosed medical problem, bill code 99201-99215 unless the follow-up includes a comprehensive examination with refraction to determine the need to corrective lenses (see above).