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Intermediate eye exam
Reporting an intermediate eye exam means there is something new to the original diagnosis.
Your patient comes in for a follow-up visit at your request due to a recent episode of keratoconjunctivitis sicca in both eyes. Today, she reports compliance with prescribed medication, decreased foreign body sensation and less tearing. She is otherwise healthy. Examination reveals improving tear function, and the remainder of the slit-lamp exam is unremarkable. Your assessment reads “improving keratoconjunctivitis, stable.” Plan indicates discontinuation of ointment, continue tears as needed and return to the clinic in 1 week. You circle intermediate eye exam (92012) on the routing slip.
Is this an appropriate use of the intermediate eye exam CPT code?
No. Unlike the evaluation and management codes, no national guidelines exist for the ophthalmology codes (920xx). Some Medicare carriers publish guidelines specific to their jurisdiction, but many carriers do not. In the absence of published guidance, the CPT manual is an appropriate source for direction. The intermediate eye exam definition in the Ophthalmology section of the chapter titled “Medicine” states: “Intermediate ophthalmological services describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy.”
Chart documentation in this example supports most, but not all, of the requirements for an intermediate eye exam. Documentation in the chart note includes a history, general medical observation and external exam. This exam is an evaluation of an existing condition; however, it is not a condition complicated with a new diagnostic or management problem. The impression indicates an improving, stable condition. A low-level evaluation and management code (9921x) best describes this encounter.
Physicians often utilize intermediate eye exam codes for glaucoma follow-up exams. In some situations, this is an appropriate choice. For example, an open-angle glaucoma patient with IOP consistently measuring 16 mm Hg presents with an IOP of 26 mm Hg. An additional glaucoma medication is added to the existing treatment, and the patient is instructed to return in 1 week to determine the efficacy. This encounter satisfies the intermediate code definition of “existing condition complicated with a new diagnostic or management problem.” With all other requirements met, this exam qualifies as 92012.
A subsequent return visit reveals a stable IOP of 15 mm Hg. The patient is instructed to continue the new medication and return in 4 months for follow-up. This exam does not satisfy the criteria for an intermediate exam because nothing new exists and the existing condition does not have a new problem. A low-level evaluation and management code (9921x) best describes this encounter.