Physicians and nonphysician providers (NPP) of all specialties use evaluation and management (E/M) codes for clinical encounters. In addition, ophthalmologists have “eye codes” at their disposal. Although it may seem that adding more choice will create confusion, both E/M and eye codes are useful tools for billing retinal exams. This article will focus solely on new patient exams, because the E/M code system has slightly different rules for new vs established patients.

THREE CODES FOR THE NEW PATIENT

First, be sure the patient actually meets the criteria for a “new” patient — that is, one who has not been seen by any ophthalmologist in the practice in the past 3 years. Once you are sure the patient truly meets “new” status, a properly documented patient retinal exam will often meet the requirements of 3 codes (Table 1). By becoming thoroughly familiar with the documentation requirements of these 3 codes, practitioners can concentrate on patient care rather than billing.

Utilization patterns tell the story. Within the Medicare program, 52% of new patient eye exams in the United States were billed in 2018 as 92004; about 32% were billed as 99204, and only about 2% were billed as 99205.¹

Remember that these national averages are for all ophthalmologists, regardless of subspecialty; a vitreoretinal subspecialist may see a more complex cohort of patients needing immediate major surgery, and skew toward a higher percentage of level 4 and 5 E/M codes. However, a specialist who sees a mix of new patients with diabetes, early dry macular degeneration, and posterior vitreous detachments that might not need surgical intervention may have a utilization rate closer to the national average.

THE COMPREHENSIVE EYE EXAM

We can correctly presume that the most commonly used new patient code in ophthalmology is a comprehensive eye exam (92004). This is considered an easily documented code and the requirements fit the usual work of a retinal exam. The rules are straightforward: One must document a chief complaint, a medical history relevant to the reason for visit. The exam must include general medical observations (ie, alert and oriented x3), gross visual fields (typically done by confrontation), extraocular motility, external eye and adnexa, ophthalmoscopy, and other exam elements relevant to the chief complaint. Most payers expect documentation of vision, intraocular pressure (IOP), conjunctiva, cornea, pupil/iris and lens, and that the fundus exam is be performed dilated (unless documented as contraindicated).

Both a diagnostic and a treatment plan are also required. Diagnostic examples include OCT, fundus/disc photos, or angiography, but even a nonbillable diagnostic test done on that day that is not part of an exam (ie, Amsler grid) can suffice. Treatment may include major or minor surgery, over-the-counter or prescribed medications, or counseling (blood sugar monitoring or following up with another provider). The physical exam requirements match what most ophthalmologists consider a complete eye exam.

EVALUATION AND MANAGEMENT CODES

Evaluation and management codes have arcane rules and more detailed documentation requirements, especially for the history components. Corcoran Consulting Group encourages readers to thoroughly learn and adhere to the requirements in order to avoid costly claim denials on audit; this column is not a deep dive into the rules and will provide a summary only.

If providers want to bill level 4 or 5 E/M codes (99204, 99205), they must be sure to hit all documentation targets. Otherwise, a lesser code will be supported, even when serious retinal disease requiring treatment is present.

Documentation requirements for E/M codes are divided into 3 sections: history, exam, and medical decision making. The ophthalmologist must attest that he or she obtained the history of present illness; if a technician obtains an initial chief complaint, the provider must review, enhance, and/or edit the information for the history of present illness (HPI) to “count” toward the documentation requirements.

The history includes the HPI, review of systems (ROS), and past/family/social history (PFSH).³ A comprehensive history requires all of the following:

• HPI: Four or more factors (eg, timing, duration, location, modifying factors);
• ROS: 10 or more systems reviewed for symptomatology (eg, cardiovascular, respiratory); and
• PFSH: Two of these 3 areas must be documented (these might include current medications and allergies, social history, relevant surgeries, family history, or tobacco/alcohol/drug use).

A comprehensive exam must include vision, IOP, gross visual fields, extraocular motility, lids/adnexa, conjunctiva, cornea, anterior chamber, pupil/iris, lens, and dilated fundus (unless documented as contraindicated). A systemic evaluation of the patient’s mental status (eg, alert and oriented, mood and affect) is also required.

If all work-up requirements are documented, the ophthalmologist may then code the exam based on medical decision making. If the patient is at moderate risk for loss of vision or function, a level 4 (99204) may be an appropriate code choice. Patients facing a high risk of loss of vision or function may qualify for a level 5 exam (99205).

THREE CATEGORIES FOR REAL LIFE

How does this look in practice? New patient retinal exams generally fall into 3 categories, coinciding with the 3 codes described here. Some examples are as follows:

• 92004 — New patient low-risk disease; treatment consisting of counseling and/or home care:
  • Diabetic patient with minimal retinopathy
  • Low-risk dry macular degeneration
  • Posterior vitreous detachment with no complicating retinal pathology
• 99204 — New patient serious, nonurgent disease; treatment consisting of scheduled surgery:
  • Diabetic patient with macular edema requiring intravitreal anti-VEGF injection
  • Wet macular degeneration requiring intravitreal anti-VEGF injection
  • Posterior vitreous detachment with concurrent low-risk atrophic hole requiring laser retinopexy
• 99205 — New patient serious disease; treatment urgent or emergent surgery:
  • Diabetic with high IOP with proliferative retinopathy and vitreous hemorrhage, requiring urgent pars plana vitrectomy and endolaser
  • Macula-on retinal hole or tear with retinal detachment, requiring urgent pars plana vitrectomy with air–fluid exchange and silicone oil or gas
  • Choroidal hemorrhage with intractable high IOP requiring pars plana vitrectomy and choroidal drainage

A WORD ABOUT RISK, PLUS ADDITIONAL CODES

While considering new patient code selection, you must avoid over-stating risk. For instance, if a procedure is offered same day for patient convenience but could otherwise wait a few days, the ophthalmologist should not up-code the exam. One may be able to offer laser retinopexy for an atrophic hole or intravitreal injection for early wet macular degeneration the same day as an exam. If the outcome would be the same if the patient were scheduled for the procedure one or two weeks hence, the exam would be a level 4 E/M, not a level 5 E/M.

Other new patient codes are also available. The new patient intermediate eye (92002) and E/M levels 2 and 3 (99202, 99203) often do not reflect the work performed for a dilated, comprehensive eye exam. However, emergencies do occur, and the retinal specialist may see a new patient with an anterior segment diagnosis. If no retinal exam is required for a patient with a corneal abrasion, for example, the exam is not comprehensive, and the physician should bill the more appropriate 92002 or 99202 exam levels.

Corcoran Consulting Group strongly recommends that ophthalmologists receive comprehensive training in appropriate documentation and coding to avoid any missteps when coding low-risk patient exams, as well as to code appropriately and confidently when a facing a patient with imminent vision loss. RP

REFERENCES

1. Corcoran Consulting Group, data extracted from CMS data in the physician/supplier procedure summary files for 2018. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary/index . Accessed January 28, 2020.
2. National payment rates from CMS.gov physician fee schedule look up tool for 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup . Accessed January 28, 2020.
3. CMS’ 1997 documentation guidelines for evaluation and management services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf . Accessed January 28, 2020.