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 a practice prior to beginning your audit. In most scenarios, practices decide on the code set they use depending on insurance payer. Others may decide depending on the conditions they are treating. Having this information prior to an audit will reduce the possibility of you second guessing which should have been used during your audit. All in all, it still all comes down to documentation.

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:

 Visual acuity;

1. Gross visual fields;
2. Extraocular motility;
3. Conjunctiva;
4. Ocular adnexa;
5. Pupils and iris;
6. Cornea, using a slit lamp;
7. Anterior chamber, using a slit lamp;
8. Lens;
9. Intraocular pressure;
10. Optic nerve discs;
11. Retina and vessels.

So how do we define the initiation of a diagnostic treatment program? It includes a prescription of medication (including glasses), arrangement of special ophthalmological diagnostic or treatment services, arranging for consultations, laboratory procedures or radiologic procedures.

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:

1. Chief compliant; history of present illness; past, family and social history; and a review of systems;
2. Examination;
3. Medical decision making.

Also, we need to consider medical necessity. For a level 3 visit we need to support an acute uncomplicated problem or a chronic stable problem. For a level 4 visit we need to support an acute problem with complicating factors, a chronic exacerbated problem, or two or more stable chronic conditions. As always, to support a level 5 service we need either an acute or chronic problem that is posing a threat to life or limb.

Diagnostic Testing

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.