Opthalmology Evaluation under the Microscope

In 2004 I took on my second specialty in Healthcare in the world of Opthalmology. I was introduced to the specialized procedures and services performed by professionals in this space.

Over the next few years I dug into this specialty learning the Anatomy, Disease Process and importance of eye health.

Years of Audits led me to dig deeper into the Evaluation and Management series of codes and compare them to the Opthalmic Evaluation series found in the medicine section of CPT.

What we find as auditors is that the components and purpose of these code sets gets blurred in the minds of coders, billers and even physicians to the point where billing them based on which fee is higher becomes the focus.

I will break down the intent, documentation requirements and medical necessity needed for either option in order for patient care to be the focus and let reimbursement come respectively.

The work of Evaluating the Eye

Ultimately we find in these Opthalmic Evaluation codes 92002-92004 and 92012- 92014 that the physician’s activity is referred to as intermediate and comprehensive. Next we want to compare the Evaluation and Management codes described in 99202-99215. As we know prior to 2021 the key components of leveling Evaluation and Management codes were the history, examination, and medical decision-making , which required guidelines found in CMS official guidelines for 1995 and 1997.

After January 1, 2021 AMA created new guidelines to simplify the reporting to limit the components to Medical Decision making and time, with Medical Necessity still driving the bus on either road. Many then asked, how does this effect the difference in reporting Opthalmic codes vs Evaluation and Management codes with History and Exam not factoring in to the leveling process for payment?

Let’s look at how Opthalmic codes are leveled at this point in time. As we see in CPT guidelines as well as the interpretation from insurance payers and the American Academy of Opthalmology the components remain as:

Intermediate New

  • Reviewing history
  • An external examination
  • An ophthalmoscopy
  • A biomicroscopy for an acute complicated condition (eg, iritis) not requiring comprehensive ophthalmological services

Intermediate Established

  • Reviewing interval history
  • An external examination
  • An ophthalmoscopy
  • A biomicroscopy and tonometry in established patient with known cataract not requiring comprehensive ophthalmological services.

Comprehensive New

  • A review of history

12 Required Exam Components :

  • Visual acuity;
  • Gross visual fields
  • Extraocular motility
  • Conjunctiva
  • Ocular adnexa
  • Pupils and iris
  • Cornea, using a slit lamp
  • Anterior chamber, using a slit lamp
  • Lens
  • Intraocular pressure
  • Optic nerve discs
  • Retina and vessels; dilated unless contraindicated and documented in chart AAO.org

One of the big differences as you can see is what is examined that relates to the eye with very specific structures being reviewed as well as history and medical decision-making. I look specifically for the mandatory components. The big question still remains, “What is the financial impact of the code choice?”

While this question is important, documentation will dictate the better choice and the care needed for the patient in relation to the condition, comorbidity and plan of care required. Let’s breakdown the financials.

Show me the Money

Let’s breakdown the reimbursement for Medicare to see how the reimbursement compares across code sets.

As you can see you will financially fare better when comparing the work and supporting documentation of levels 2 and 3 in the Evaluation and Management code set. Then once you get into the work of Levels 4 and 5 you see significant payment differences due to the patient’s condition, comorbidities, data reviewed and analyzed as well as significant risk. In those cases once the risk increases you may find yourself choosing Evaluation and Management codes.

Evaluation and Management vs Ophthalmic Code Analysis

Eye Code Limitations

We always encourage our clients to choose the code options based on the documentation but sometimes commercial payer rules and the place of service will dictate your options.

Some commercial payers have limitations with diagnosis restrictions when linking eye codes vs other medical codes. There are some payers that are also issuing denials and down coding when eye codes are reported with a medical diagnosis. This will limit when an eye code can be billed.

For instance if your diagnosis involves Diabetes without an ocular manifestation then the payer may require you bill an Evaluation and Management code instead of a Ophthalmic code.

You will also find rules vary by state as well. Due to the many varying rules, having clear policies and documentation reviews annually is recommended. You can create reference tools to help your staff complete requirements and ensure accurate payment.

Another tip I always advise is to lay it out both ways. Code both ways, compare the documentation requirements, look at the diagnosis and Payer requirements. I recommend creating a decision template to audit yourself each time they are reported to avoid incorrect and non compliant billing of these codes.

It is always recommended that you have transparent conversations with your patient. Many have medical and vision benefits and by reviewing the chief complaint in addition to the patient benefits you can correctly document and support the best service.

Contact Jmcnamara@oncospark.com to discuss what our Subject Matter Experts in Ophthalmology can do to help your practice.

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