New / Established Patients
Before we get into coding, it’s important to define new patients vs. established patients.
- A new patient is someone who has not been seen by the doctor or any of the associates within the practice in the last three years.
- An established patient has been seen by the doctor or any of the associates within the practice within the last three years.
For any vision care plans like VSP, Spectera, Eyemed, Superior Vision, VBA, etc., we use 92004 (for new patients) or 92014 (for established patients) with 92015 (refraction code) for a comprehensive eye exam.
- Initiation of diagnosis and treatment has to occur with comprehensive eye exams.
You can also use 92002 and 92012 for an intermediate exam, which may include dilation, but it is not necessary and does not require start of a treatment.
For Medicaid patients, an S code is required
However, check with your state to find out whether or not they accept S codes. While researching, I learned that some states do not pay if you use S codes and require you to use 92XXX codes. S0620 is the code for new patients and S0621 is for established patients. These both include refraction within the code itself, you do not bill it separately.
Coding for Medical Exams
Coding for medical exams get a little confusing especially if you do not have any experience in coding.
Examples of medical exams can be diabetic exams, annual glaucoma or macular degeneration exams or any office visits. The codes are 99201-99205 or 92002 - 92005 for new patients and 99211-99215 or 92012 - 92015 for established patients.
When I was researching, I learned that if you code a medical visit (99xxx) as an intermediate visit (92002/92012), the reimbursement rates are higher. You can click here to find out what Medicare will reimburse you for certain codes.
With 99xxx medical exams, you need to have a chief complaint and history of present illness. Review of systems, patient family history, physical exam, diagnosis/management and medical decision making depends on the level of coding you use e.g. level 1, level 2, level 3, level 4 or level 5.
|Level||E & M||HPI||ROS||PFSH||Physical Exam**||Risk|
|4||99214||4||Ocular & 2 ROS||1 of PFSH||9||moderate|
|5||99215||4||Ocular + 10||3 for new2 for est||All||High|
Physical Exam elements include**
- confrontation fields
- optic nerve
- posterior segment
- orientation and mood and affect
The Definitions of 92xxx codes and 99xxx codes
CPT-4 2012 Definition: “… describes 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 ophthalmological 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. Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision making cannot be separated from examining techniques used. Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry or motor evaluation is not applicable.”
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT’S AND/OR FAMILY’S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. source
CPT-4 2012 Definition: “… describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily related 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.”
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT’S AND/OR FAMILY’S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. source
Coding for Medically Necessary Contact Lenses
For contact lens fittings, 92310 is a standard code. However, different codes are used for keratoconus (92072) and ocular surface diseases (92071). Corneal topography (92025) can be billed if it is medically necessary for conditions like keratoconus, irregular astigmatism, corneal dystrophies, etc.
This is very basic, but it will help you get started with everyday coding.
McGreal Jr., J.A. Understanding medicare guidelines:2014.
Cargo, J. Basics of coding and billing for the optometric staff. http://texas.aoa.org/documents/tx/215%20-%20CARGO-%20Coding%20and%20Billing%20for%20Staff.pdf
The author of the content you just read worked hard to provide you with this article. Even though we try our best, there is no guarantee the article is error free. CovalentCareers, its sponsors, advertisers, staff and writers make no representation, warranty, or guarantee that this article and its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained within.