New ophthalmologists come out of residency and fellowship ready to treat eye diseases and perform surgeries. However, during the training process, coding and documentation often take a back seat to surgery and patient care.
This article seeks to assist new ophthalmologists in understanding documentation requirements and selecting suitable codes for office visits. The importance of choosing proper codes is twofold: understanding the documentation requirements for each code helps reduce under-coding and ensures physicians receive proper compensation for the work performed.
Using E/M and eye codes to maximize reimbursement
Before jumping into the details, it is important to know that eyecare physicians have the flexibility to utilize both Evaluation and Management (E/M) codes (99xxx) and eye codes (920xx). For many payors, these codes are interchangeable.
Understanding both eye and E/M codes allows the ophthalmologist to maximize reimbursement by choosing the code that most accurately represents the level of service.
The rest of this article discusses the key elements of documenting the medical necessity of office visits, the required components for eye codes, and the Medical Decision Making (MDM) criteria for E/M code selection.
Documenting office visit medical necessity
The reason for the visit, the chief complaint (CC), establishes medical necessity. Without an appropriate CC, a third-party reviewer could deny the claim as non-covered. That means, regardless of using an eye or E/M code, every office visit must have a CC.
Recording the chief complaint
The Medicare Benefit Policy Manual (MBPM) states Medicare excludes routine checkups from coverage: “The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint…”1
Additionally, Palmetto, a Medicare Administrative Contractor (MAC), defines the CC as "a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the patient encounter."2 Essentially, the CC determines whether the service is a covered benefit and is mandatory for all levels of service.
After capturing the CC, the provider has discretion with the content of the other elements of the patient history. The patient's medical history typically involves the history of present illness; review of systems; medical, social, and family history; medications; and allergies. While obtaining a thorough history is typical during the initial patient visit, it may not be necessary at every encounter.
Both the eye code criteria and E/M guidelines give physicians latitude to determine what is medically necessary. For example, Current Procedural Terminology (CPT) lists “history” and “general medical observation” as criteria for both the intermediate eye code (92002/92012) and comprehensive eye code (92004/92014).
Following the 2021 changes to the E/M criteria, a “medically appropriate” history, as determined by the treating physician, satisfies E/M code selection.3
Download the Essential Ophthalmology Coding Cheat Sheet here
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Essential Ophthalmology Coding Cheat Sheet
This essential guide to coding and billing for new ophthalmologists lists eye and E/M codes to utilize for office visits.
Components of eye and E/M code physical exams
There is slightly more contrast between eye and E/M codes when it comes to the physical exam elements. As with history, the exam requirements shifted significantly with the 2021 E/M update. For E/M codes, a “medically appropriate” exam satisfies the requirements.
As a result, physicians have the flexibility to tailor exams to align with the patient complaints, signs, or symptoms. For example, if a patient complains of a foreign body sensation in the right eye, the physician may only examine the anterior segment of the right eye. Similarly, if a patient describes floaters in the left eye, the physician may choose to only dilate and examine the left eye.
In contrast, CPT lists specific exam components to meet the requirements of the intermediate (92002/92012) and comprehensive (92004/92014) codes.
Table 1 compares the CPT criteria for the intermediate eye code and comprehensive eye code.
| Exam Element | Intermediate Eye Code (92002/92012) | Comprehensive Eye Code (92004/92014) |
|---|---|---|
| History | X | X |
| General Medical Observation | X | X |
| Evaluation of Complete Visual System | X | |
| External and Adnexal Exam | X | X |
| Confrontation Visual Fields (CVF) | X | |
| Extraocular Movement (EOM) | X | |
| Ophthalmoscopy (With or Without Dilation) | X | |
| Other Pertinent Exam Elements | X | X |
| Diagnostic Test | X | |
| New or Worsening Condition | X | |
| Treatment | X | X |
Table 1: Courtesy of Brittney Irwin, COT, CPC-A, CEP.
Many payors expect the comprehensive eye code (920x4) to include an evaluation of the eye, including a dilated fundus exam. For those reasons, it is important to review any payor-specific policies.
Keep in mind, some insurance providers may have limits on how frequently a comprehensive eye code can be billed within a 1-year period. Billing a comprehensive eye code too frequently may be viewed as over-coding.
How new ophthalmologists can accurately select E/M codes
In 2021, the AMA revised and simplified outpatient office visit E/M code selection, allowing providers to use MDM or total physician time.
There are four levels of MDM that are the same for both new and established patients:
- Level 2 (99202/99212) or straightforward MDM
- Level 3 (99203/99213) or low MDM
- Level 4 (99204/99214) or moderate MDM
- Level 5 (99205/99215) or high MDM
Further, MDM is defined by three categories:
- The number and complexity of problem(s) addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management.
Two of the three categories must be met to reach that level of service. Eyecare physicians conduct various diagnostic tests, but since most are internal, they don't contribute to the data component of MDM, which relies on unique external sources. Therefore, we’ll spend our time discussing the problems addressed and the risk of complications during the MDM process.
How to document adressing a problem with E/M codes
According to the American Medical Association (AMA), a problem is defined as "a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter."3
A problem is considered addressed when it undergoes evaluation or treatment during the encounter by the reporting physician. Conversely, merely listing a diagnosis, indicating another provider’s management of the problem, or sending a referral without an evaluation do not qualify as addressing the problem within the encounter.
Risk of complications and/or morbidity or mortality of patient management
The AMA states that the risk of complications and/or morbidity or mortality of patient management “includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision-making with the patient and/or family.”3
The AMA only provides examples of risk associated with moderate and high levels of service within their E/M table.4 Prescription drug management is listed as an example of moderate risk. Although the AMA does not expand on this example, Novitas, a MAC, does.
Novitas states, “Prescription drug management does not require a new drug, a new dosage, or a discontinuation of a current prescription. The medical record will show the physician work to determine the medical necessity of the prescription drugs. An encounter documented as only a prescription refill without documentation of a problem addressed would not suffice.”5
Per the AMA, “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified healthcare professional reporting the service. Credit can be given for prescription medications considered but can not be given due to patient choice, possible drug interactions, etc. Prescription drug management does not include drugs injected during the current or subsequent encounter.”5
It's important to note that not all encounters discussing prescription drugs satisfy the moderate level 4 E/M code. Physicians must consider all three components of MDM, not just the risk associated with the treatment, to determine the appropriate service level.
Selecting the E/M Code Based on MDM
To satisfy any level of E/M code (99202–99215), the documentation must meet or exceed two of the three components at the specific level. Usually, this means we can drop the lowest category (which, in eyecare, is typically data), and then choose the lowest remaining category as our level of service.
Let’s review an eye-specific example using the MDM table:
- Scenario: An established patient returns for a 3-month follow-up for primary open-angle glaucoma (POAG). A medically appropriate history and exam are documented. The patient’s intraocular pressure (IOP) is stable on timolol.
- The physician emphasizes compliance with timolol QAM OU and asks the patient to return in 3 months for an optic nerve (ON) optical coherence tomography (OCT) and IOP check.
- Problems Addressed: Stable POAG describes one stable chronic illness satisfying the “low” category of MDM.
- Amount and/or Complexity of Data to be Reviewed and Analyzed: The ON OCT is an internal test with separate reimbursement; therefore, it lands in “minimal/none.”
- Risk of Complications and/or Morbidity or Mortality of Patient Management: Prescription drug management discussing compliance with timolol falls into the “moderate” category.
If we follow the instructions and drop the lowest category, data, and then select the second lowest, we are left with choosing 99213 or a low level of MDM. Conversely, if the patient had a second problem addressed during the encounter, then the documentation would support two stable chronic illnesses with prescription drug management, resulting in a moderate level of MDM or a level 4 E/M code.
Table 2 outlines the considerations for using E/M codes for a 3-month follow-up appointment.
Table 2: Courtesy of Brittney Irwin, COT, CPC-A, CEP.
Final thoughts: Office visit coding in practice
In conclusion, understanding the nuances of office visit coding is crucial for new ophthalmologists navigating the complexities of reimbursement and documentation requirements. The opportunity to use both E/M and eye codes provides flexibility and helps optimize reimbursement.
By adhering to the guidelines and understanding the necessary components for documenting medical necessity, ophthalmologists can ensure proper coding and billing practices.
Ultimately, mastering these coding principles empowers ophthalmologists to provide high-quality care while navigating the intricacies of reimbursement.
