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The Ongoing Debate: E/M vs. Eye Codes
No single code typifies a "glaucoma exam." Here's a look at some of the distinctions that will guide you.
By Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., San Bernardino, Calif.

Eye examinations can by codified in at least 14 different ways, excluding consultations and hospital visits. Four ophthalmic visit codes (920xx) constitute the most popular current procedural terminology (CPT) codes, and ten evaluation/management (E/M) codes (992xx) round out the lot. Glau-coma is so varied in form and severity that you could cite examples for all 14 codes using just this one disease.

The distinctions between the levels of service rely on differences in the patient's history, the examination and the complexity of medical decision-making. Difficult cases -- for example, patients whose disease isn't well controlled -- justify higher levels of service and more reimbursement. Simpler reevaluations of well-controlled patients use lower levels of service. Examinations of patients with acute glaucoma, one of very few emergent ocular conditions, may justify the highest level of service (992x5). Even minimal eye examinations (99211) performed by technicians may apply when performed under physician supervision.

Some Medicare statistics may help you evaluate your levels of service as compared to the national average.

Practice patterns

The distribution of eye examinations performed on Medicare beneficiaries has a characteristic pattern, as illustrated by the bar graph on page 6. You can reasonably assume that examinations for glaucoma follow the same pattern.

The table above, "Medicare Utilization Rates for Optometrists," describes the percentage of examinations in each level of service for office visits by new and established patients based on Medicare's 2000 BESS (Part B Extract and Summary System) data for the country. This data includes both E/M and ophthalmic visit codes. You can compare your own practice patterns to Medicare's utilization data by tabulating the number of examinations for a significant time period, say 3 months.

This table combines E/M codes (992xx) with the corresponding eye codes (920xx). Codes that are side-by-side are nearly equivalent in terms of the amount of reimbursement as well as the extent of the documentation. In this way, you can understand the overall utilization rates without regard to the ongoing debate about coding preferences.

Some cautions are in order for any statistics. First, Medicare's data isn't the "right answer." It represents a conglomeration of many things, some good, some bad. For instance, it includes claims for generalists as well as specialists, who often see more patients with advanced disease. No doubt, some of this data represents upcoding and some downcoding.

Remember, too, that practice patterns are not homogeneous around the country. The northeast and northwest are more conservative than the southeast or southwest. Finally, because this data represents paid claims, it under-reports services rendered because some claims don't get paid, although they should be.

Even considering all the problems with statistics, comparing your practice patterns with Medicare's can reveal some interesting anomalies, although explanations may not be readily available. Further study is generally rewarding.

E/M vs. eye codes

Fortunately, you have two sets of codes from which to choose. You're not required to always use E/M codes, but often can select an eye code instead. These are the eye examination codes in the Ophthalmology section of CPT (92002 to 92014). The documentation requirements -- especially the history -- are much easier for most practitioners to meet.

Although the eye codes won't cover every possible situation, they'll suffice for most examinations. You'll still need to use E/M codes for services that don't fit within the guidelines for eye codes. For complex or very difficult cases, you should use higher level E/M codes. Conversely, lower level E/M codes will best describe follow-up visits and examinations for uncomplicated problems.

CPT recognizes that eye 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."

Most Medicare carriers have published policies that follow CPT very closely, although a few have specifically stated that some components are required for a comprehensive examination. In particular, several Medicare carriers have adapted the numerical elements aspect of the E/M guidelines to the eye codes. These carriers specify eight or more elements for a comprehensive eye examination (92004, 92014) and three to seven for an intermediate eye examination (92002, 92012). Check your individual carrier's policies.

Eye code visits are either comprehensive or intermediate for both new and established patients.

CPT defines a new patient as one who has not received any professional services from the physician or another physician of the same specialty in the same group practice within the past 3 years.

  

 If a patient declines to be dilated at the initial exam but returns in a day or so for dilation, you would submit one claim for a bridged exam.

Comprehensive exams

Comprehensive eye examination codes (92004, 92014) describe a general evaluation of the complete visual system. CPT defines the code 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."

Note that gross visual fields and basic sensorimotor examination are required for a comprehensive eye examination. Interestingly, other elements of an examination that most practitioners would expect to include are not required. For instance, dilation is listed as optional in the CPT description, although some Medicare carriers have published policies stating that it is required.

Also note that CPT defines these codes as "one or more visits." These codes describe a single service that need not be performed at one session. In other words, you can bridge an examination over more than one session in a day (morning and afternoon) or more than
1 day (start today, complete the examination tomorrow). This can happen when a patient declines to be dilated during the initial examination and returns at another time to complete the dilated examination. In that case, you'd submit one claim, and your medical record would reflect the fact that the examination extended over time. Presumably, the time span between visits is short, usually no more than a day or two. The notion of a bridged exam does not apply to E/M services.

Intermediate exams

Intermediate codes (92002, 92012) are defined 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 is optional.

The requirement that the examination include a new condition or an existing condition complicated with a new diagnostic or management problem means that many follow-up exams for chronic, stable conditions won't qualify as intermediate eye exams (92012). When this is the case, the only option is to return to the E/M codes and choose an Expanded Problem Focused (EPF, 99213) or Problem Focused (PF, 99212) exam.

Some clinicians use the eye codes exclusively to describe office visits and select an intermediate eye exam as the smallest charge for a patient encounter. This approach represents an oversimplification as well as upcoding for a portion of the exams that should have been described as E/M codes. Some payers have become aware of this self-serving billing pattern and have successfully recaptured overpayments in several cases.

Crosswalk  

92004 = 99203

92002 = 99202

92014 = 99214

92012 = 99213   

  

Using the crosswalk

For some third party payers, it's helpful to translate an eye code to an E/M code or vice versa. A crosswalk is an effective tool for making the translation based on the values assigned by Medicare to E/M and eye codes as well as the chart documentation requirements defined in CPT.

The table above closely approximates equivalent codes.

Advantage: Eye codes

You have many choices to describe eye examinations. You can choose either ophthalmology (eye) codes or E/M codes, depending on the situation. The five levels of E/M codes are universally applicable for all manner of ailments, yet they're complicated and necessitate at least two pages of chart documentation for a comprehensive examination.

Eye codes have several advantages:

Consequently, an eye code usually is preferred to an E/M code.

A few payers deem eye codes as the province of routine eye care, but this arbitrary rule is a minority view and has no basis in CPT. And remember, when the payer won't accept your initial claim, a crosswalk from eye codes to E/M codes is a useful work-around.