Eye Codes vs. E/M Codes: The Ongoing Debate

Donna McCune, CCS-P, COE, San Bernardino, Calif.
6/14/2007

Q: As an eye-care provider, should I exclusively choose eye codes (920xx) or evaluation and management codes (992xx) to describe office visits?

 

A: Neither. Most eye-care providers use a combination of eye codes and E/M codes. Data from 2005 shows that ophthalmologists used the eye codes on 70 percent of Medicare claims and E/M codes (excluding consultations) on 30 percent. This has been changing in recent years. In 2005, the new patient level 4 E/M code (99204) adjudicated by Medicare increased from 15 percent of new patient office visit claims to 19 percent of new patient office visit claims. This reduced slightly the use of the new patient comprehensive eye exam code, 92004.


 

Q: Is there an advantage to using eye codes more than E/M codes?


A: Yes. Many reasons exist to support the use of eye codes instead of an E/M code when the documentation supports a choice. They include:


 
Simple definitions. The eye code definitions in the CPT book use terminology familiar to eye-care providers.

 Straightforward documentation requirements.

 Two levels of service. Only two types of exams exist, comprehensive and intermediate.

 Specificity. These codes are specific to vision-care providers. Ophthalmologists and optometrists can bill eye-exam codes. Although it is possible that an internist could use these codes, it is unlikely. Because these codes apply to a small subset of health-care providers, they may draw less attention than the E/M codes.


 

Q: Is there a financial advantage to using the eye codes instead of an E/M code when the documentation supports a choice?


A: Commercial contracts and fee schedules vary, so this requires a payer-by-payer analysis. Eye codes used to be reimbursed quite a bit higher than the similar E/M code from Medicare. However, the 2007 Medicare Physician Fee Schedule did not include a review of the relative value units apportioned to the eye codes. The E/M RVUs were reviewed and, in many situations, increased. Therefore, the earlier financial advantage for the eye codes was narrowed and, in some cases, eliminated in the Medicare fee schedule. For example, the level 3 established patient E/M code, 99213, increased 13 percent from 2006 to 2007 compared with the intermediate eye code, 92012, which decreased 5 percent from 2006 to 2007. The reimbursement difference between these two codes is approximately $2 on a national level (Medicare reimbursements differ based on geography).


 

Q: Are the eye codes utilized for refractive error and the E/M codes for ocular disease and systemic disease?


A: No. Medicare accepts eye codes or E/M codes without consideration to the diagnosis. Of course, Medicare coverage is dependent on the chief complaint and subsequent diagnosis. Some commercial payers may differentiate "routine care" with refractive diagnoses for the eye codes and "medical care" for E/M codes. This is a payer policy, and no precedent exists to support this approach.


Many Medicare carriers publish a policy for "general ophthalmological services" that contains a list of acceptable diagnoses. All ocular diseases and many systemic diseases which affect the eyes are contained in these policies. Refer to your local Medicare carrier's policy for the exact list of acceptable ICD-9 codes. These diagnosis codes would also apply if an E/M code is used; however, there are few, if any, published policies specific to coding with E/M codes. Other third-party payers may not publish policies for the eye codes or E/M codes.


 

Q: Are documentation requirements consistent state-by-state for eye codes and E/M codes?


A: No. There is no national policy applicable to the eye codes. Many Medicare carriers do not publish local coverage policies for these services. Others publish detailed policies. In the absence of a policy, defer to the definitions in the CPT book for the eye codes. If your carrier publishes a policy, be sure to review it as it may contain additional documentation requirements not cited in the CPT book definition. For example, the use of mydriasis for the fundus exam is optional in the CPT description, but some Medicare carriers (e.g., TrailBlazers Health) require the use of mydriasis for the fundus exam to satisfy a comprehensive eye exam.


Providers may hesitate to use the E/M codes because the system is complex. Satisfying the higher-level codes requires a great amount of documentation that may not fit on one piece of paper. The history-taking requirements are very specific and, if not complete, can down-code a new patient encounter by two levels of service. The decision-making component is subjective and physicians struggle with interpreting the table of risk.

 

Q: If the eye codes are much easier to use, why can't I use them exclusively and ignore E/M codes?


A: The eye codes do not describe all types of office visits. In situations where the gravity of the condition is severe, high-level E/M codes more accurately describe the service, and the reimbursement is commensurate with the level of exam and associated risk. For conditions that are straightforward and do not meet the definition for an eye code, the lower- level E/M codes are more applicable. Regardless of the code selected, the medical record documentation must support its use.

 

Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.