April 19th, 2019
Auditing Ophthalmology and Optometry Exams
If you work in an ophthalmology group or audit ophthalmology then you are most likely aware of the caveats that exist in this specialty. Ophthalmology and Optometry practitioners can select from either the E/M code set or the Ophthalmologic exam code set. Having this knowledge in your pocket allows you to have a great opening discussion with
Ophthalmologic Services Code Set
New patient codes 92002 and 92004, established patient codes 92012 and 92014 are distinguished as intermediate or comprehensive exams. The most common misconception of the difference between these exams is that the comprehensive exam requires dilation and the intermediate exam does not. The major difference between these two codes is that the comprehensive exam includes the initiation of a diagnostic treatment program. The comprehensive exam also contains 12 exam elements:
- Gross visual fields;
- Extraocular motility;
- Ocular adnexa;
- Pupils and iris;
- Cornea, using a slit lamp;
- Anterior chamber, using a slit lamp;
- Intraocular pressure;
- Optic nerve discs;
- Retina and vessels.
So how do we define the initiation of a diagnostic treatment program? It includes a prescription of medication (including glasses),
An intermediate exam consists of less than the 12 elements and does not require the initiation of a diagnostic treatment program. Dilation can also be done in an intermediate exam.
E/M Services Code Set
New patient codes 99201-99205 and established patient codes 99212-99215 can also be selected, but the use of them requires adherence to the established 1995 or 1997 E/M Coding Guidelines as well as being supported by medical necessity. As an auditor, this is where I find much of the coding errors, as either the documentation does not support the level of service, or the medical necessity does not support the level of service. In new patient visits documentation needs to include:
- Chief compliant;
historyof present illness; past, family and social history; and a review of systems;
- Medical decision making.
Also, we need to consider
Pachymetry, fundus photography, visual field testing, OCT, TearLab, or GDX are all separately reportable, but remember that the interpretation and report of these procedures must be included in your documentation. Should the EMR software not have the capability to embed this information into the encounter note, make sure that it is added to the documentation you receive to audit. This is also a good tip for your clients, should the software not be able to add this information into the encounter notes, should they need to send records to an insurance carrier, they need to know to include the added documents.