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.
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
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
Eye code visits are either comprehensive or intermediate for both new and established
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.
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 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 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.
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:
They're suitable for most eye diseases and conditions, except the very simple cases
and the most complex assessments.
They're easily understood, with simple definitions and just two levels of service
from which to choose.
All required chart documentation readily fits on a single page.
They're usually reimbursed at a higher rate than the corresponding E/M codes.
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.