CODING Q&A

Using the Eye Codes for Retina Exams

Information Provided By Riva Lee Asbell

While performing recent audits, I noticed many retinal physicians using CPT code 92014 (Comprehensive, established patient) with intravitreal injections and for other follow up visits. I would like to devote this column to explaining the specific circumstances for using 92014 and how the Comprehensive exam requirements differ from the Intermediate exam requirements.

Definition and Requirements of the Eye Codes

Intermediate Exam

Definition: Evaluation of a new or existing condition complicated with a new diagnostic or management problem, not necessarily relating to the primary diagnosis

Examination Requirements

► History
► General Medical Observation
► External Ocular and Adnexal Examination
► Other Diagnostic Procedures as Indicated

Code descriptions for Intermediate Eye Codes

92002: Ophthalmological services: medical examination and evaluation, with initiation of diagnostic and treatment program; intermediate, new patient

92012: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

Comprehensive Exam

Definition: Describes a general evaluation of the complete visual system. The comprehensive services constitute a single-service entity but need not be performed at one session.

Examination Requirements

► History
► General Medical Observation
► External Examination
► Ophthalmoscopic Examination
► Gross Visual Fields
► Basic sensorimotor examination
► It always includes initiation of diagnostic and treatment programs.

Initiation of diagnostic and treatment program includes prescribing medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.

Code descriptions for Comprehensive Eye Codes

92004: Ophthalmological services: medical examination and evaluation, with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits

92014: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

Medical Necessity Issues

The medical necessity issues regarding the Comprehensive eye codes are complex — there must be medical necessity for the service as well as all of the elements performed. Furthermore, the physician must perform all the required elements in order for them to be counted toward the level of the examination. This includes confrontation visual fields and extraocular muscle balance evaluation. When a person is being followed at frequent intervals for a serious disease, such as endophthalmitis or uveitis, the more appropriate code is an E/M code, such as 99214, if all other requirements are met. There probably is no medical necessity for confrontation visual fields and/or EOM evaluation in the absence of new symptoms.

Additionally, if your plan is to continue the same medications, for example, you have not met the requirement to initiate a diagnostic and treatment program. Even though the descriptor allows “continuation” for established patients, the mandatory requirement of “initiation” of a diagnostic and treatment program remains.

In practice, the Intermediate exam requirements are easier to fulfill since the physician almost always performs examination of the Lids/Adnexa and the slit lamp examination. RP

CPT codes copyrighted 2012 by the American Medical Association.