Coding & Reimbursement

Eye Codes vs. E/M codes

By Suzanne L. Corcoran, COE

Physicians and staff continue to experience confusion about when to use eye codes (920xx) and when to use evaluation & management (E/M) codes (992xx) for office visits. While this topic is too complex to address completely in this column, here are some helpful hints.

Q. Should I use exclusively eye codes or E/M codes?

A. No. To best describe the variety of services you provide, you need to use a combination of the two.

Q. Why do providers hesitate to use the E/M codes?

A. The E/M coding system is complex. Satisfying the higher level codes requires a lot of documentation that may not fit on one piece of paper. The history-taking requirements are very specific and, if not complete, can downcode a new patient encounter by two levels of service. The decisionmaking component is subjective and physicians struggle with interpreting the table of risk.

Q. Is there an advantage to using eye codes rather than E/M codes?

A. Many reasons exist to support the use of eye codes instead of an E/M code when the documentation supports a choice. They include:

► Simple definitions. The eye code definitions in the CPT book utilize terminology familiar to eyecare providers

► Straightforward documentation requirements. The documentation requirements in the CPT book for these codes are easily understood and met

► Two levels of service. Only two types of exams exist, comprehensive and intermediate

► Not universal. These codes are specific to eyecare providers.

There may be financial advantages to using eye codes when possible, although much depends on the payer. Medicare generally allows more for eye codes than for comparable E/M codes. Because commercial contracts and fee schedules vary, it requires a payer-by-payer analysis.

Q. If the eye codes are so much easier to use, why can't I just use eye codes and ignore E/M codes?

A. Despite their ease of use, the eye codes do not describe all types of office visits. In situations where the gravity of the condition is severe, high level E/M codes more accurately describe the service and the reimbursement is commensurate with the level of exam and associated risk. For conditions that are straightforward and do not meet the definition of an eye code, the lower level E/M codes are more applicable. Regardless of which code is selected, the medical record documentation must support its use.

Q. Is it true that the eye codes are utilized for refractive error and the E/M codes refer to ocular disease and systemic disease?

A. Not for most payers. Medicare accepts eye codes or E/M codes without consideration to the diagnosis. Of course, Medicare coverage is dependent on the chief complaint and subsequent diagnosis. Some commercial payers may differentiate "routine care" with refractive diagnoses for the eye codes and "medical care" for E/M codes.

Q. Where can I find the guidelines for the eye codes and E/M codes?

A. The eye codes are defined in the CPT book under the Medicine/Ophthalmology section. Further details are found in specific carrier policies. The E/M coding guidelines can be found on the CMS Web site (www.cms.hhs.gov); many local Medicare carriers also publish them on their Web sites.

Q. What is the utilization of the eye exam codes in comparison to the E/M codes?

A. According to the 2006 BESS (Part B Extract Summary System) data for Medicare paid claims, ophthalmologists utilized the eye codes on 70% of Medicare claims and E/M codes (excluding consultations) on 30% of Medicare claims.

Q. Are there any other codes from which to choose to describe an eye exam?

A. Some commercial payers accept HCPCS Codes to describe routine eye exams. The codes S0620, routine eye exam, new patient, including refraction and S0621, routine eye exam, established patient, including refraction describe routine care for patients with a refractive diagnosis or ammetropia. Medicare does not accept these codes. Reimbursement varies by payer. OM