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Medicare coding: differentiating eye exams vs. medical care and counseling
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The level and type of care clinicians provide when treating medical patients and scheduling follow-up visits determines the current procedural terminology (CPT) codes used for reimbursement under Medicare and Medicaid. Optometrists must especially have a complete understanding of the 92 and 99 series codes to avoid reimbursement problems and misuse that could result in an audit by the Health Care Financing Administration (HCFA).
“Often, code usage is a judgment call, depending on what happens when you see a patient, how much time you spend with him or her and what you spend your time doing,” said Scott A. Edmonds, OD. “If you are giving an eye exam and not giving medical care and counseling, you use the 92 series codes. If you get into medical counseling, then bill as a medical visit using the 99 codes.”
However, use caution when using the 99 series. They should only be used if the practitioner is very comfortable with his or her level of medical expertise, Dr. Edmonds warned. The 99 codes require more documentation at all levels, he explained, and this is where many optometrists get into trouble.
“The 99 codes come into play when you are providing medical care and counseling and deciding upon a course of action for the patient,” he said. “If you end up with a medical discussion regarding the patient’s disease and future course of action, that is what they call your decision-making step.” If the practitioner is not sure whether a visit should be billed using the 99 or 92 series of codes, use 92, Dr. Edmonds advised.
Donald A. Hood, OD, a managed care expert in practice in Denver is even more cautious. “An optometrist can typically bill for a level 1, 2 or 3 office visit in the 99 series,” he said. “If you get into level 4 or 5, you may get audited. Unless the optometrist is a subspecialist in a clinic with extra training, he or she does not do a level 4 or 5. Medicare pays level 4, but you are waving a red flag that says ‘come audit me.’”
Dr. Edmonds warned: If you have been sloppy with coding in the past and have gotten away with it, that does not mean that you should think you can continue to get away with it. “That’s not healthy thinking. It doesn’t mean that the hammer is not going to come down on you,” he said.
Coding for diabetes patients
Dr. Edmonds explained several patient scenarios in an interview with Primary Care Optometry News, outlining the proper code usage for each.
In an annual check-up for an established diabetes patient, Dr. Edmonds said he would perform a dilated fundus exam. “We actually wouldn’t do anything different for a diabetic, but we would be looking a little more carefully at the retina for evidence of microaneurysms and early retinal edema,” he said. “The billing would be 92014, because you are primarily performing an eye exam.”
Dr. Edmonds said refractions are billed separately, using the code 92015. “Refraction is defined as a separate procedure from the examinations under the new rules,” he said.
However, Dr. Hood added: “Annual refers to routine, and Medicare does not pay for routine care. Legally, you cannot get reimbursed for an annual exam even if the patient has diabetes, cataracts or glaucoma. But if the patient says, ‘I am concerned about my diabetes,’ that is a medically focused purpose for the exam and the doctor must record that. Most optometrists know this, but many don’t and they are vulnerable,” Dr. Hood said. “If they get audited by HCFA and routine eye exams are on there, that’s fraud.”
Follow-up schedule for diabetes
Clinical findings would require the practitioner to see the patient again sooner. “If I saw background retinopathy or a few dot and blot hemorrhages,” Dr. Edmonds said, “I would see the patient back in 6 months. I might also see the patient back in 6 months if he or she was not stable on insulin or was otherwise more at risk. A follow-up schedule should take into account how the patient’s diabetes is being managed.”
At that hypothetical 6-month follow-up visit for a diabetic patient, Dr. Edmonds said he judges how to bill based upon what happened at the visit. “If I saw a patient at 6 months because I thought he or she was medically unstable, but there were no ocular findings and the exam was clean again, I would probably bill as 92014 again.
“If I found diabetic retinopathy on that 6-month visit, I would have to think about using the medical code 99214,” Dr. Edmonds continued. “In this case, I provide much more of what I consider to be medical care, because I am counseling and advising relative to medical problems. This is a level 4 office medical visit.”
This particular scenario could be billed as a level 5 office visit under certain circumstances. “I would even use the 99215 code if I end up spending an additional 45 minutes of counseling with a patient after the examination,” Dr. Edmonds said. “If his or her vision is severely affected and you have to discuss driving and other life-changing consequences, it might get up to a level 5. The level of exam is heavily based on how much history, decision making and counseling you do.”
Coding, follow-up for cataract patients
For a cataract patient, both Drs. Edmonds and Hood said that the same factors outlined above apply. For a standard patient with a mild cataract who is pseudophakic in the other eye, provided he or she is doing well and is being seen at an annual exam, the code would be 92014 and 92015, a comprehensive eye exam and refraction. Dr. Edmonds added that given the cataract is minimally symptomatic, he would see the patient next at 1 year.
“For a patient with a cataract in one eye who is pseudophakic in the other eye, my follow-up would be 3, 6 or 12 months, depending upon how the new cataract looked, how far I think it will advance and what the patient’s symptoms were,” Dr. Edmonds explained. “If that developing cataract was giving the patient night-driving problems or reduced vision, or if it was posterior subcapsular, which tends to grow very quickly, I might see the patient back in 3 months.”
If Dr. Edmonds spends a lot of time with medical considerations, he said he would be justified in billing at 99213, 99214 or 99215. “But I would just code a level 3 medical visit as an eye exam because the reimbursement is better,” he said. “When you do enough medical care that you get to a level 4 office visit, that’s when you start to consider coding as a medical office visit.”
Coding, follow-up for glaucoma patients
Glaucoma patients are usually seen quarterly or every 4 months for intraocular pressure (IOP) checks. Dr. Edmonds said, “You’re usually just doing a pressure check, counseling the patient about the medicines, making sure he or she is taking them correctly and asking about side effects. This is usually a level 3, or sometimes a level 4, medical office visit: 99213 or 99214.”
If a glaucoma patient comes in for a quarterly visit and his or her vision has changed, Dr. Edmonds said he could end up performing an eye exam and a refraction, but this does not occur often.
Dr. Hood cautioned: “This is where optometry is the most exposed for malpractice, because glaucoma is so easy to miss. This is often where doctors don’t do enough or follow enough, and then people lose their vision.”
He explained that if the patient’s pressures are moving, the practitioner should see him or her as often as every 2 months to try to maintain stability. “If a patient starts to deteriorate, most optometrists will refer to a specialist,” he said.
Acute office visits
When a patient comes in with an acute condition, the practitioner will usually use the 99 codes and whatever level of office visit is appropriate.
“For a patient with conjunctivitis, I would use the 99 codes,” said Dr. Edmonds. “If a patient suspected conjunctivitis but just had a subconjunctival hemorrhage, that might just be level 2. But if he or she had epidemic keratoconjunctivitis, where I had to do a lot of counseling about not spreading it and I had to swab down my office after he or she left, I might use level 4.”
One difficult scenario, Dr. Edmonds described, is a diagnosis and rehabilitation management of macular degeneration. “This one is controversial,” he said. “When you are seeing this patient, you are not doing much classic medical treatment, as this is usually provided by the retina specialist and you will not get actively involved unless something dramatic happens. Most of the time, you are evaluating a patient’s function and then providing rehabilitation services. You are performing vision-related testing, but it isn’t a refraction. I code these sessions as 99 office visits. For the most part, they are level 4s and 5s.
“Even though you are not lasering the macula, you are dealing with the patient’s history and how the symptoms have altered his or her life,” he continued. “All of that is medically oriented and centered around an ocular disease.”
He explained that many optometrists don’t understand this distinction, believing that they cannot use a 99 code because they are not actively treating the lesion. “I take the position that what I am doing is totally related to medical problems and, therefore, medical care. A lot of my colleagues don’t agree,” Dr. Edmonds said. “They’ll do vision function testing and bill the patient for a low vision refraction with a modified 92015 code, which virtually no insurance company covers, and therefore charge the patient 100% out of pocket.”
Use the medical codes
Dr. Edmonds said that optometrists are licensed to use medical office visit codes under Medicare regulations, so they should use them. “Medicare says we are physicians; the services we provide, other than a specific refraction, are related to managing that ocular disease, and we are entitled to use those codes,” he said.
He added that optometrists may also use the consult code for referred patients, 99241-99245.
For Your Information:
- Scott A. Edmonds, OD, can be reached at Suite 53 MOBE Lankenau Hospital, Wynnewood, PA 19096; (610) 896-7261; fax: (610) 896-5245; e-mail: sedmonds@edmondsgroup.com.
- Donald A. Hood, OD, can be reached at 1550 S. Potomac St., Ste. 155, Aurora, CO 80012; (303) 369-1020; e-mail: donhoodod@aol.com.