coding
E/M vs. Eye Codes: Making the Choice
Part 3 of this series focuses on choosing the best coding options.
BY RIVA LEE ASBELL

As we are nearing the end of the decision-making process, some distinguishing factors should be apparent. Eye Codes are vague. There are no sharp divisions between history, examination and medical decision-making. They are all lumped together, whereas the E/M codes are quite specific. For me, the E/M codes are easier to defend under audit.

The final installment of this three-part series will provide guidance in choosing the best coding option for a variety of patient encounters. Parts 1 and 2 of the series appeared in the October and November 2006 issues of Ophthalmology Management.

The Code Sets Differ

Eye Code examination requirements vary from carrier to carrier. You must have medical necessity for the service itself as well as each examination element you are performing. You cannot decide "I always bill 92014 twice a year." There must be medical necessity for the level of service in both sets of codes. The four elements of comprehensive Eye Code examination and one element of intermediate Eye Code examination are set by CPT dictate. You have no choice. Thus, there must be medical necessity for each element. In E/M codes you have a choice of elements. It is a quantitative requirement. Any of the elements fulfill the numerical requirement as long as there is medical necessity.

Compliance means different things to us all; however, in terms of Medicare coding and reimbursement, it means adhering to Centers for Medicare & Medicaid (CMS) regulations and making sure that your chart documentation supports the code and level of service that you have chosen. Medicare does not want you to overcode or undercode. Audits are conducted for both mistakes. There is no problem in selecting an appropriate code that is also remuneratively rewarding.

Code Selection

The chart on page 34 shows the main codes available for coding office encounters in nonfacility and facility settings. The Relative Value Units (RVUs) will remain the same in 2007 even if the conversion factor is changed by Congress, as it was last year. Thus, the differential remains the same although the dollar amount may change.

The higher-level E/M codes realized gains whereas the lower levels more or less maintained their RVUs. In reality, you probably will only be using five or so of the codes in everyday practice. Let's see how the algorithm works.

New Patients/Consultations

At the end of the day, when you finish examining the patient and your patient documentation is filled out properly, ask yourself, "What adjective should I choose that best describes my level of participation in the E/M codes?" If your answer is "Low," you are at E/M level 3; if your answer is "Moderate," you are at E/M level 4, and if your answer is "High," you are at E/M level 5.

■ New Patients. If your level is 4 or higher, then you should probably be using E/M codes. If your level is 3 or lower, you probably should be using Eye Codes, unless you fail to initiate a diagnostic and treatment program at the comprehensive eye code level. In this case, you will have to drop to 99203. This guidance applies to both facility and nonfacility providers. Private practices generally fall under the heading of nonfacility, whereas academic medical centers usually are classified as facility. 

Let's look at an example.

A patient is examined with complaints of difficulty seeing out of the right eye, etc. A comprehensive history is taken and a comprehensive examination is performed. It is determined that the patient has a cataract and surgery is scheduled. The adjective is "Moderate," so you would use CPT code 99204.

The next patient comes in with similar complaints, but has only an early cataract and receives a new prescription for glasses and to return in 6 months. The adjective would be "Low," so the level is 3. A comprehensive Eye Code (92004) is the better choice over the appropriate E/M code (99203).

■ Consultations. If your adjective is 3 (Low) or higher, the E/M consultation code should be used. If not, switch to the Eye Codes.

An example would be a patient presenting for consultation for opinion and advice concerning possible macular degeneration. Once again, a comprehensive history is taken and a comprehensive examination is performed. A diagnosis of dry macular edema is made. There are no other significant clinical findings. Your adjective is "Low." The choice is between a consultation and an office visit. This encounter is a consultation and would be at the level 3, so the code is 99243.

This is true for both facility and nonfacility providers. Be aware that there is no such thing as a new patient consultation.

Return Office Visits

92012 vs. 99213. For return office visits for conditions requiring more frequent visits, the choice is often between CPT codes 99213 and 92012. An error was made in the RVU calculation in 1998 and the erroneous calculation was maintained until 2007. This resulted in significantly higher reimbursement ($12.50 in 2006)
for code 92012 until 2007. There still remains a differential of $1.44 in favor of 92012 in 2007. However, facility providers should note that the differential is $8.28. Given the choice, the Eye Code pays better than the E/M code and can be generally used in most instances.

92014 vs. 99214. Code 92014 basically should be used when coding for comprehensive eye examinations and not for follow-up visits for serious disease. It has lost its financial advantage this year.

Use 92014 for your follow-ups where medical necessity dictates a comprehensive examination, such as a return in 1 year for cataract follow-up. The code is not intended to be used for frequent follow-up visits for serious pathological conditions.

Use 99214 when following serious diseases as long as your medical decision-making is "Moderate" and you have the medical necessity to perform nine of the elements. This code has been a target of Office of Inspector General (OIG) investigations and you should be confident of your coding skills and chart documentation when using it. You will see on the chart that the reimbursement is almost the same for nonfacility providers. However, for facility providers there is a huge differential in favor of the E/M code ($10.80).

99212. Most Medicare local policies on the Eye Codes mandate for minimal services that code 99212 be used — not 99213 or 92012. Quick check-ups for conjunctivitis or healing corneal abrasions would fall into this category.

In conclusion, I hope that this series has provided you with a logical methodology for solving the dilemma when faced with choosing between E/M and Eye Codes. You should be mixing your use of the codes to maintain compliance while optimizing reimbursement at the same time.

Numbers given are national averages.

CPT Codes copyright 2006 American Medical Association

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com.