Ophthalmology Medical Billing and codes

Ophthalmology is a subspecialty of medicine (MD) that focuses on eye and vision treatment. Ophthalmologists are specially trained to conduct eye examinations, diagnose and treat disease, give medication, and perform eye surgery. Additionally, they issue prescriptions for spectacles and contact lenses.

Ophthalmology medical coding can be highly complicated because of the disparate documentation requirements for E/M, intermediate, and comprehensive Eye codes, disparate fee schedules, and coverage policies, a high volume of bundle revisions, and the requirement to apply modifiers to assure compliance.

Medicare and private insurance organizations have distinct billing policies for ophthalmology. Even within Medicare, individual Medicare Administrative Contractors (MACs) have varying standards, including how bills should be coded and the paperwork required.

Ophthalmology Medical Billing and codes

For example, Medicare mandates clinicians to bill bilateral claims by adding the modifier 50 to the procedure code on the claim. Commercial payers, on the other hand, require you to enter the procedure code on one line with the modifier LT and then the modifier RT on the subsequent line.

To ensure that you are paid on the first submission, you must be familiar with and adhere to each payer’s rules. Constantly verify payer policies, exam elements accomplished, and medical necessity criteria. If you bill Medicare, subscribe to CMS email updates to be notified of coverage changes.

One best practice is to construct a payer matrix that details your most often billed codes and the differences between them.

Optometry Coding Guidelines

Optometrists have the distinct advantage of being able to use both the 92002-92014 General Ophthalmological Service and the 99202-99215 Evaluation and Management codes. Only eye doctors are permitted to use the 92xxx codes, which are valid for both medical and regular exams. Medical billing codes 99xxx are used by all health care practitioners and are limited to medical-only examinations with further rules to follow.

99xxx codes are assigned based on the documentation of the patient’s medical history, examination components, and medical decision-making. As a result, you must first determine your performance on each during the exam. The health history is classified into four categories based on the level of detail included in the Chief Complaint, HPI History of Current Illness, Review of Systems and Past, and Family and Social History.

CPT Codes 92004, 92014, 92002, and 92012

The 92xxx codes have fewer guidelines to follow and can be broken down into two levels: comprehensive CPT code 92004 and CPT code 92014, and intermediate CPT code 92002 and CPT code 92012.

  • CPT code 92004 descriptions: Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.
  • CPT code 92014 descriptions: Medical examination and evaluation with initiation or continuation of diagnostic treatment program; comprehensive, established patient, one or more visits.

The comprehensive exam often includes a retinal evaluation and typically is not performed more than once a year. The 92002/92012 eye exam CPT codes are more often used for anterior seg issues or follow-up visits.

Optometry Procedure Codes

Along with the optometry CPT codes for office visits, you must be conversant with procedure codes such as bilateral procedures 92250 Fundus Photos and 92083 Threshold Visual Fields. Bilateral operations have a single price regardless of whether the procedure is performed on one or both eyes. When executing the operation on two eyes, unilateral procedures such as 65222 Corneal Foreign Body Removal allow for a price for each eye.

Ophthalmology Services and Procedures

92002 – 92014: General Ophthalmological Services and Procedures

92015 – 92287: Special Ophthalmological Services and Procedures

92310 – 92326: Contact Lens services

92340 – 92371: Spectacle Services

92499: Other Ophthalmological services and procedures

Know When to Bill a Patient’s Vision or Medical Insurance

Due to the fact that patients have both medical and vision insurance, it can be challenging to determine which to bill, even more so when patients request that you charge one over the other.

Vision insurance covers “regular” eye examinations and most policies cover one every calendar year. Medical insurance, on the other hand, is applicable when a medical symptom or continuing care for a medical condition occurs.

Many eye tests are covered by both vision and medical insurance, however, most insurance companies focus on the primary complaint and diagnosis. For instance, suppose a patient presents with red-eye. Because red-eye is a symptom of an underlying medical condition, you would bill medical insurance for the appointment, not vision insurance.

To ensure correct guidance, it is always prudent to verify with your payers regarding their eye exam policies. Additionally, verify your patient’s eligibility for medical and vision insurance prior to the office visit.

Diagnostic testing bills must be accurate:

  • Diagnostic testing for ophthalmology billing is constantly inspected, and any infringement can result in more serious consequences for healthcare practitioners.
  • Healthcare practitioners must pay close attention to accurate modifiers in order to generate accurate codes that adhere to the requirements.
  • Visual field testing is a routine component of ophthalmic care. Never attempt to report visual field tests with 92081-92083 because this is considered upcoding.
  • Clinical ophthalmology testing does not have to be reported bilaterally. Perform it once on a claim, regardless of whether it is performed on one or both eyes.
  • Examine the documentation to determine if it supports medical necessities.
  • Acquire a working knowledge of technical modifiers so that healthcare practitioners can bill the A-scan component only once, even if it is for both eyes. As a result, it is classified as bilateral.
  • The components of professionalism are unilateral. Prior to surgery, separate computations can be made on each eye.