exam coding
Coding Eye Exams
Follow these suggestions for insight into headache-free coding.
BY JOHN M. B. RUMPAKIS, O.D., M.B.A, Lake Oswego, Ore.

In an ideal world, professors of Optometry 101 would teach coding for eye exams because it's such a basic foundation within our practices. Yet, in the 150-plus presentations I give each year on coding and billing, I find widespread confusion among our peers. This is cause for concern mainly because many practitioners (or perhaps most) don't know how to properly code our most frequently performed service: the eye exam.

I find that the vast majority of eyecare professionals with whom I speak aren't only using the improper codes and modifiers to code the exam, but are unfamiliar with the specific examination requirements associated with each code to use it properly. Additionally, many are also wrongly employing techniques such as a time-of-service discount or a -52 modifier (reduced services) to benefit the private-pay patient.

Not only are we making things more difficult than necessary, but more worrisome is that these practices may put many optometrists under the intense scrutiny of an insurance company auditor. Fortunately, simple, easy and appropriate methods of properly coding and getting appropriate payment for our services do exist.

Understanding the basics

There are at least 16 ways that we can code eye examinations in an optometric practice (excluding consultation visits). Understanding what codes we should use and their respective definitions is paramount in the world of coding. The standard code sets used in ophthalmic practices consist of the ICD-9 codes for diagnoses, the CPT codes for most procedures and the Health Care Procedural Coding System (HCPCS) codes for procedures not covered under the CPT umbrella. Most carriers have published policies that follow the CPT closely, although it's not uncommon to find that they may have specific policies or guidelines that build on the CPT definition for a particular code.

Always be sure of a carrier's specific policy regarding billing a code rather than simply relying on the CPT definition. These policies are generally available on the carrier's Web site and are referred to in current nomenclature as Local Coverage Determinations (LCDs) or as Local Medical Review Policies (LMRPs) in older language. Irrespective of the acronym used, they serve the same function in defining the appropriate guidelines in using a particular code.

Those 16 essential codes

The 16 codes I referred to previously include four ophthalmic visit codes (920XX), 10 evaluation and management (E/M) codes (992XX) and two HCPCS "S" codes (S062X). All are appropriate for coding eye examinations that occur within an optometric practice.

We're fortunate to have these three codes sets from which to choose -- optometry is one of the few subspecialties to have its own office visit codes. Most often in coding eye examinations, we use the 920XX codes because it's easier for most practitioners to meet the documentation requirements, particularly the history components.

Although these codes won't cover every possible situation, they're probably the best to use for most general examinations. You'll still need to use E/M codes for services that don't fit within the guidelines for eye codes. The CPT recognizes that ophthalmic codes work on a principle different from E/M codes, particularly with regard to detailing all of the components of an examination:

"Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision-making cannot be separated from the examining techniques used. Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry or motor evaluation is not applicable."

Eye code visits are either comprehensive or intermediate for both new and established patients. Keep in mind the definition of a new patient is one who hasn't received any professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Below are the (most common) 920XX codes:

92002 (Ophthalmological services): Medical examination and evaluation with initiation of diagnostic treatment program; intermediate, new patient.

92004 (Ophthalmological services): Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.

92012 (Ophthalmological services): Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.

92014 (Ophthalmological services): Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.

It's also critical to understand that refraction (CPT 92015) isn't a part of any of the above-mentioned codes. It's a distinct and separate service that we should always bill as a separate line item on our claim form with a distinct and separate fee.

Now that we've reviewed the specific codes, let's take a look at the different visit types.

The comprehensive exam

Comprehensive eye examination codes (92004, 92014) describe a general evaluation of the complete visual system. The CPT defines it as:

". . . includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs."

Keep in mind that a comprehensive eye examination by definition requires gross visual fields and a basic sensorimotor examination, while other elements of an examination that most of us would expect to include aren't required. Notably, the CPT definition lists dilation as optional, although many carriers have policies stating that it's required unless medically contraindicated.

The CPT definition also states that these codes define an examination that occurs on "one or more visits." These codes describe a single service that need not be performed in one session. Simply stated, you can complete an examination over more than one visit in a day (morning and afternoon) or more than one day (start today, complete the examination tomorrow).

The most common application of this principle is when a patient declines dilation during the initial examination and returns at another time to complete the dilated portion of the exam. In this case, you'd submit one claim and your medical record would reflect the fact that the examination took more than one visit. The "one or more visit" concept doesn't apply to E/M services.

The intermediate exam

CPT defines intermediate codes (92002, 92012) as:

". . . an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy."

As with comprehensive visits, dilation may be optional. Some clinicians use the intermediate codes to reduce the cost of an examination to a noninsured patient. This is inappropriate, as it's considered downcoding a service that was provided. Many carriers have become aware of this billing pattern and have recaptured overpayments for their insured patients for similar services.

The E/M codes

Typically, eyecare practitioners don't use the E/M codes for what most of us consider a general eye examination. They are more typically used for patient encounters where the patient presents with a medical complaint or a continuation of medical case management (i.e., glaucoma, allergy, dry eye). The five levels of E/M codes are universally applicable for all manner of ailments, yet they're more complicated to apply and require more than one page of chart documentation for a comprehensive examination.

As we know, these codes have much more specific requirements of fulfillment in the areas of case history, elements of examination and medical decision making. While appropriate in the medical management of a patient, using them to code a general examination would again tend to put you in harm's way under the scrutiny of an audit, where we have a better CPT code in the 920XXs that most appropriately describes the services provided.

And keep in mind that payers usually reimburse the 920XX codes at a higher rate than the corresponding E/M code.

The routine exam

The "S" codes are a subset of the HCPCS codes. Whereas the CPT codes are more specifically known as the Level One codes, the Level Two codes are codes healthcare providers use on a national basis for coding procedures where a formal CPT code is not in existence or inadequately describes a procedure. They help to describe procedures more specifically for internal coding whereas third-party insurance carriers don't recognize or accept all Level Two HCPCS codes.

Optometry's training in understanding the basis for coding an eye exam has generally been limited to the information that the vision insurance/refractive insurance plans have provided. By and large, all refractive carriers have instructed us (by contract) to use the 920XX codes for describing each and every eye examination -- often including refraction in the code. Yet, as described earlier, we know two definite things:

1. The 920XX codes aren't for routine patients

2. Refraction has never been included within the definition of a 920XX examination service.

Two codes specifically aid eyecare practitioners in our providing of routine eye care: S0620 and S0621. They represent "routine ophthalmological examination including refraction" for new and established patients respectively. The dilemma that most eyecare practitioners face is choosing the appropriate code for eye examinations while maintaining their fees at appropriate levels for the services they provide. Because reimbursements for 920XX services are generally much higher than what most charge for their "general eye examinations," they have concern for the private-pay patient.

Many doctors worry that if they set their existing examination fee schedules to these third-party reimbursement levels, they'll lose business to their lower-priced competitors. By defining a separate service, they let you set a different fee that may be more acceptable. By employing these "S" codes correctly, doctors now have the ability to set their fee structure for providing the appropriate level of care for their patients. They're especially helpful when you're coding routine eye exams -- those healthy patients without complaints who come in for a regular check-up and for new glasses or contact lenses.

Beware of discrimination

Insurance guidelines specify that you have one fee schedule for each CPT code. Thus when you establish a price for providing a 92004, you must charge all patients the same fee for the same service, regardless of who's paying the bill. Multiple fee schedules are discriminatory and, at a minimum, could lead to reduced reimbursements from your carriers if they establish a pattern of discount. In a worst-case scenario, a carrier could determine that you've been abusive in your billing patterns and demand monetary damages. S codes provide a viable method to avoid the multiple/discount fee patterns that often exist. Let's look at several potential scenarios.

Scenario one. The patient has both refractive and medical insurance.

► If the patient presents with a chief complaint and a refractive diagnosis, we would bill either the S code (at its specific fee level) or a 920XX code plus refraction to the refractive carrier.

► If the patient presents with a chief complaint and a medical diagnosis, we would bill the medical carrier for the appropriate 920XX or 992XX level of service and bill the patient or the patient's refractive insurance for the refraction if we performed one.

Scenario two. The patient has refractive insurance, but no medical insurance.

► If the patient presents with a chief complaint and a refractive diagnosis, we would bill either the S code (at its specific fee level) or a 920XX code plus refraction to the refractive carrier.

► If the patient presents with a chief complaint and a medical diagnosis, we would bill the patient for the appropriate 920XX or 992XX level of service, and bill the patient or the patient's refractive insurance for the refraction if we performed one.

Scenario three. The patient has no refractive insurance, but has medical insurance.

► If the patient presents for a routine exam and has a refractive diagnosis, we would bill the appropriate S code (at its specific fee level) to the patient. #009;

► If the patient presents with a chief complaint and a medical diagnosis, we would bill the medical carrier for the appropriate 920XX or 992XX level of service and bill the patient, or the patient's refractive insurance, for the refraction if we performed one.

Scenario four. The patient has neither refractive nor medical insurance.

► If the patient presents for a routine exam and has a refractive diagnosis, we would bill the appropriate S code (at its specific fee level) to the patient. #009;

► If the patient presents with a chief complaint and a medical diagnosis, we would bill him for the appropriate 920XX or 992XX level of service, plus the refraction if we performed one.

Informed coding pays off

When performing a routine examination on a healthy-eyed patient, these codes are a good alternative to the usual CPT codes that were developed with a "sick" patient in mind. Careful patient differentiation of routine eye exams versus patients presenting with either a complaint or a pre-existing condition allows the office to appropriately bill the patient privately or through insurance or Medicare.

This ability to be price-competitive can be an additional advantage within the competitive eyecare marketplace, allowing you to maximize per-patient profits while attracting new, price-sensitive patients for routine exams. They also allow you to maintain good compliance with insurance guidelines for single-fee schedules by enabling you to set your fees for routine examinations competitively while still capturing appropriate reimbursements for commensurate services provided by CPT guidelines. Moreover, they reduce the temptation to apply inappropriate time of service, prompt pay discounts or the misuse of the -52 modifier. They keep our practices safely within coding guidelines, our prices appropriately set for the services performed and our patients happy.

Dr. Rumpakis is the president and CEO of Practice Resource Management Inc., a medical consulting firm. He is the author of ReimbursementPlus.com, a Web-based CPT Reimbursement & Fee-Setting application. He's a member of the AOA and the American Academy of Professional Coders.