The “Eyes” Have it: Routine vs. Medical Eye Exams
- By admin aapc
- In Coding
- November 2, 2012
- 20 Comments
by Nancy Clark, CPC, CPMA, CPC-I
Understanding the difference between routine and medical eye examinations will guide you to properly code these services and prevent your patient from receiving an unexpected bill. Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.
CPT® codes 92002-92014 indicate new and established eye exams, and are used for both routine and medical visits. The primary diagnosis code makes the distinction.
New patient:
• 92002 Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
• 92004 ...comprehensive, new patient, 1 or more visits
Established patient:
• 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
• 92014 …comprehensive, established patient, 1 or more visits
A routine visit is indicated by a primary diagnosis code of V72.0 Special investigations and examinations; examination of eyes and vision, followed by any additional diagnostic findings. For example, if an eye exam is coded as 92002 with a primary diagnosis of V72.0, it is considered a routine exam; however, 92002 with a primary diagnosis of 379.91 Pain in or around eye would be considered a medical exam.
When a patient presents for an eye exam due to poor eyesight, he may believe this service to be covered by insurance. But insurers do not consider refractive errors (e.g., nearsightedness and farsightedness) to be medical diagnoses, and many do not cover routine vision exams. Consequently, there may be confusion on the patient’s part if his insurance company denies the service.
Clear up the confusion before the service is rendered by contacting the patient’s health insurance and determining if routine vision services are covered, the frequency of coverage, and if the patient has met or exceeded his limit of routine services. Ask the patient if he has separate vision coverage under another carrier. Ensure that your patient understands the difference in exams and what his insurance covers.
Nancy Clark, CPC, CPMA, CPC-I
Chief complaint determines whether or not the eye examination is routine or medical in nature. CMS is very clear on this:
The Medicare Carriers Manual, Part 3 §2320 reads:
“The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.”
Comprehensive or intermediate ophthalmological examinations performed under the contract of a refractive plan are deemed to be “routine in nature” as they are a prepaid benefit and generally exempt from the chief complaint requirement. They are not reduced services, just payable outside of the medical plan in a refractive carve out. The diagnosis has really nothing to do with the examination being routine or not, as the ICD-9 code simply describes the condition of the patient post examination.
I work in ophthalmology…this has always been an issue for us but we are on top of it all…Some patients may have coverage for a routine vision exam paid under preventivie care on their medical insurane (anthem as an example) so we would use v72.0 as diagnosis code for 92002 thru 92014 cpt codes/ some insurances do not cover the eye refraction (cpt code 92015) which is also an important part of the eye exam