Using the Eye Codes for Retina Exams
Information Provided By Riva Lee Asbell
|Riva Lee Asbell can be contacted at www.rivaleeasbell.com, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.|
While performing recent audits, I noticed many retinal physicians using CPT code 92014 (Comprehensive, established patient) with intravitreal injections and for other follow up visits. I would like to devote this column to explaining the specific circumstances for using 92014 and how the Comprehensive exam requirements differ from the Intermediate exam requirements.
Definition and Requirements of the Eye Codes
Definition: Evaluation of a new or existing condition complicated with a new diagnostic or management problem, not necessarily relating to the primary diagnosis
► General Medical Observation
► External Ocular and Adnexal Examination
► Other Diagnostic Procedures as Indicated
Code descriptions for Intermediate Eye Codes
92002: Ophthalmological services: medical examination and evaluation, with initiation of diagnostic and treatment program; intermediate, new patient
92012: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
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.
► General Medical Observation
► External Examination
► Ophthalmoscopic Examination
► Gross Visual Fields
► Basic sensorimotor examination
► It always includes initiation of diagnostic and treatment programs.
Initiation of diagnostic and treatment program includes prescribing medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.
Code descriptions for Comprehensive Eye Codes
92004: Ophthalmological services: medical examination and evaluation, with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
92014: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
Medical Necessity Issues
The medical necessity issues regarding the Comprehensive eye codes are complex — there must be medical necessity for the service as well as all of the elements performed. Furthermore, the physician must perform all the required elements in order for them to be counted toward the level of the examination. This includes confrontation visual fields and extraocular muscle balance evaluation. When a person is being followed at frequent intervals for a serious disease, such as endophthalmitis or uveitis, the more appropriate code is an E/M code, such as 99214, if all other requirements are met. There probably is no medical necessity for confrontation visual fields and/or EOM evaluation in the absence of new symptoms.
Additionally, if your plan is to continue the same medications, for example, you have not met the requirement to initiate a diagnostic and treatment program. Even though the descriptor allows “continuation” for established patients, the mandatory requirement of “initiation” of a diagnostic and treatment program remains.
In practice, the Intermediate exam requirements are easier to fulfill since the physician almost always performs examination of the Lids/Adnexa and the slit lamp examination. RP
CPT codes copyrighted 2012 by the American Medical Association.