coding strategies

Using the 92 Codes

Understand the required components of the four codes.

DOUGLAS K. DEVRIES, O.D.

Enter any casual-dining restaurant located in a warm climate, and you’ll often see: “Shoes and Shirt Required,” or the pointed, “No Shirt, No Shoes, No Service.” Enter one of the 92000 codes without the required components, and Medicare and private insurance companies will kick your submission to the curb.

The 92000 codes are:

• 92004 New Patient Comprehensive Examination

• 92002 New Patient Intermediate Examination

• 92014 Established Patient Comprehensive Examination

• 92012 Established Patient Intermediate Examination

The following are required for reimbursement:

Reason for visit/chief complaint

This is the medical reason, condition or symptoms that justify you performing an ophthalmic exam. Without a medical reason, no need exists to perform an evaluation on the patient.

Keep in mind that a medical ophthalmic exam does not have to include a manifest refraction for billing purposes. If the exam does include a manifest refraction, however, you should bill 92015 Determination of Refractive State in addition to the exam code selected.

The “new” or “established” patient, as correctly defined

A patient is “new” only if you or another doctor in the practice hasn’t seen him/her within the last three years, says the American Medical Association’s (AMA) 2013 CPT manual. So, it is possible that a patient you’ve seen for years could be considered a “new” patient. Also, a patient you’ve never seen is “established” on the first encounter if another doctor in your practice has seen him/her within the past three years.

Examination type

Two types of ophthalmic exams exist: The comprehensive exam and the intermediate exam.

The new patient comprehensive examination (92004) and the established patient comprehensive examination (92014) are “a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service 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,” says the AMA’s 2013 CPT manual.

The new patient intermediate examination (92002) and the established patient intermediate examination (92012) are “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,” says the AMA’s 2013 CPT manual.

Both examinations must include an initiation of diagnostic and treatment programs.

While local Medicare carriers or private insurance companies may define the number of necessary elements in the intermediate and comprehensive ophthalmic examination, the CPT does not. The evaluation and management codes specify elements for each level. OM

DR. DEVRIES HAS A DEGREE IN FINANCIAL MANAGEMENT FROM THE UNIVERSITY OF NEVADA SCHOOL OF BUSINESS AND IS CO-FOUNDER OF EYE CARE ASSOCIATES OF NEVADA, A MEDICAL/SURGICAL CO-MANAGEMENT REFERRAL PRACTICE. E-MAIL HIM AT DRDEVRIES@NVEYELASER.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.