Essential Coding Guide for New Ophthalmologists with Cheat Sheet (2024)

This essential coding guide for new ophthalmologists covers how to maximize reimbursem*nt with E/M and eye codes and office visit coding with a cheat sheet.

New ophthalmologists come out of residency and fellowship ready to treat eye diseases and perform surgeries. However, during the training process, coding and documentation often take a back seat to surgery and patient care.

This article seeks to assist new ophthalmologists in understanding documentation requirements and selecting suitable codes for office visits. The importance of choosing proper codes is twofold: understanding the documentation requirements for each code helps reduce under-coding and ensures physicians receive proper compensation for the work performed.

Using E/M and eye codes to maximize reimbursem*nt

Before jumping into the details, it is important to know that eyecare physicians have the flexibility to utilize both Evaluation and Management (E/M) codes (99xxx) and eye codes (920xx). For many payors, these codes are interchangeable.

Understanding both eye and E/M codes allows the ophthalmologist to maximize reimbursem*nt by choosing the code that most accurately represents the level of service.

The rest of this article discusses the key elements of documenting the medical necessity of office visits, the required components for eye codes, and the Medical Decision Making (MDM) criteria for E/M code selection.

Documenting office visit medical necessity

The reason for the visit, the chief complaint (CC), establishes medical necessity. Without an appropriate CC, a third-party reviewer could deny the claim as non-covered. That means, regardless of using an eye or E/M code, every office visit must have a CC.

Recording the chief complaint

The Medicare Benefit Policy Manual (MBPM) states Medicare excludes routine checkups from coverage: “The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint…”1

Additionally, Palmetto, a Medicare Administrative Contractor (MAC), defines the CC as "a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the patient encounter."2 Essentially, the CC determines whether the service is a covered benefit and is mandatory for all levels of service.

After capturing the CC, the provider has discretion with the content of the other elements of the patient history. The patient's medical history typically involves the history of present illness; review of systems; medical, social, and family history; medications; and allergies. While obtaining a thorough history is typical during the initial patient visit, it may not be necessary at every encounter.

Both the eye code criteria and E/M guidelines give physicians latitude to determine what is medically necessary. For example, Current Procedural Terminology (CPT) lists “history” and “general medical observation” as criteria for both the intermediate eye code (92002/92012) and comprehensive eye code (92004/92014).

Following the 2021 changes to the E/M criteria, a “medically appropriate” history, as determined by the treating physician, satisfies E/M code selection.3

Download the Essential Ophthalmology Coding Cheat Sheet here


Essential Ophthalmology Coding Cheat Sheet

This essential guide to coding and billing for new ophthalmologists lists eye and E/M codes to utilize for office visits.

Components of eye and E/M code physical exams

There is slightly more contrast between eye and E/M codes when it comes to the physical exam elements. As with history, the exam requirements shifted significantly with the 2021 E/M update. For E/M codes, a “medically appropriate” exam satisfies the requirements.

As a result, physicians have the flexibility to tailor exams to align with the patient complaints, signs, or symptoms. For example, if a patient complains of a foreign body sensation in the right eye, the physician may only examine the anterior segment of the right eye. Similarly, if a patient describes floaters in the left eye, the physician may choose to only dilate and examine the left eye.

In contrast, CPT lists specific exam components to meet the requirements of the intermediate (92002/92012) and comprehensive (92004/92014) codes.

Table 1 compares the CPT criteria for the intermediate eye code and comprehensive eye code.

Exam ElementIntermediate Eye Code (92002/92012)Comprehensive Eye Code (92004/92014)
General Medical ObservationXX
Evaluation of Complete Visual SystemX
External and Adnexal ExamXX
Confrontation Visual Fields (CVF)X
Extraocular Movement (EOM)X
Ophthalmoscopy (With or Without Dilation)X
Other Pertinent Exam ElementsXX
Diagnostic TestX
New or Worsening ConditionX

Table 1: Courtesy of Brittney Irwin, COT, CPC-A, CEP.

Many payors expect the comprehensive eye code (920x4) to include an evaluation of the eye, including a dilated fundus exam. For those reasons, it is important to review any payor-specific policies.

Keep in mind, some insurance providers may have limits on how frequently a comprehensive eye code can be billed within a 1-year period. Billing a comprehensive eye code too frequently may be viewed as over-coding.

How new ophthalmologists can accurately select E/M codes

In 2021, the AMA revised and simplified outpatient office visit E/M code selection, allowing providers to use MDM or total physician time.

There are four levels of MDM that are the same for both new and established patients:

  • Level 2 (99202/99212) or straightforward MDM
  • Level 3 (99203/99213) or low MDM
  • Level 4 (99204/99214) or moderate MDM
  • Level 5 (99205/99215) or high MDM

Further, MDM is defined by three categories:

  1. The number and complexity of problem(s) addressed during the encounter.
  2. The amount and/or complexity of data to be reviewed and analyzed.
  3. The risk of complications and/or morbidity or mortality of patient management.

Two of the three categories must be met to reach that level of service. Eyecare physicians conduct various diagnostic tests, but since most are internal, they don't contribute to the data component of MDM, which relies on unique external sources. Therefore, we’ll spend our time discussing the problems addressed and the risk of complications during the MDM process.

How to document adressing a problem with E/M codes

According to the American Medical Association (AMA), a problem is defined as "a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter."3

A problem is considered addressed when it undergoes evaluation or treatment during the encounter by the reporting physician. Conversely, merely listing a diagnosis, indicating another provider’s management of the problem, or sending a referral without an evaluation do not qualify as addressing the problem within the encounter.

Risk of complications and/or morbidity or mortality of patient management

The AMA states that the risk of complications and/or morbidity or mortality of patient management “includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision-making with the patient and/or family.”3

The AMA only provides examples of risk associated with moderate and high levels of service within their E/M table.4 Prescription drug management is listed as an example of moderate risk. Although the AMA does not expand on this example, Novitas, a MAC, does.

Novitas states, “Prescription drug management does not require a new drug, a new dosage, or a discontinuation of a current prescription. The medical record will show the physician work to determine the medical necessity of the prescription drugs. An encounter documented as only a prescription refill without documentation of a problem addressed would not suffice.”5

Per the AMA, “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified healthcare professional reporting the service. Credit can be given for prescription medications considered but can not be given due to patient choice, possible drug interactions, etc. Prescription drug management does not include drugs injected during the current or subsequent encounter.”5

It's important to note that not all encounters discussing prescription drugs satisfy the moderate level 4 E/M code. Physicians must consider all three components of MDM, not just the risk associated with the treatment, to determine the appropriate service level.

Selecting the E/M Code Based on MDM

To satisfy any level of E/M code (99202–99215), the documentation must meet or exceed two of the three components at the specific level. Usually, this means we can drop the lowest category (which, in eyecare, is typically data), and then choose the lowest remaining category as our level of service.

Let’s review an eye-specific example using the MDM table:

  • Scenario: An established patient returns for a 3-month follow-up for primary open-angle glaucoma (POAG). A medically appropriate history and exam are documented. The patient’s intraocular pressure (IOP) is stable on timolol.
    • The physician emphasizes compliance with timolol QAM OU and asks the patient to return in 3 months for an optic nerve (ON) optical coherence tomography (OCT) and IOP check.
  • Problems Addressed: Stable POAG describes one stable chronic illness satisfying the “low” category of MDM.
  • Amount and/or Complexity of Data to be Reviewed and Analyzed: The ON OCT is an internal test with separate reimbursem*nt; therefore, it lands in “minimal/none.”
  • Risk of Complications and/or Morbidity or Mortality of Patient Management: Prescription drug management discussing compliance with timolol falls into the “moderate” category.

If we follow the instructions and drop the lowest category, data, and then select the second lowest, we are left with choosing 99213 or a low level of MDM. Conversely, if the patient had a second problem addressed during the encounter, then the documentation would support two stable chronic illnesses with prescription drug management, resulting in a moderate level of MDM or a level 4 E/M code.

Table 2 outlines the considerations for using E/M codes for a 3-month follow-up appointment.

Essential Coding Guide for New Ophthalmologists with Cheat Sheet (1)Essential Coding Guide for New Ophthalmologists with Cheat Sheet (2)

Table 2: Courtesy of Brittney Irwin, COT, CPC-A, CEP.

Final thoughts: Office visit coding in practice

In conclusion, understanding the nuances of office visit coding is crucial for new ophthalmologists navigating the complexities of reimbursem*nt and documentation requirements. The opportunity to use both E/M and eye codes provides flexibility and helps optimize reimbursem*nt.

By adhering to the guidelines and understanding the necessary components for documenting medical necessity, ophthalmologists can ensure proper coding and billing practices.

Ultimately, mastering these coding principles empowers ophthalmologists to provide high-quality care while navigating the intricacies of reimbursem*nt.

Don't forget to download the Essential Ophthalmology Coding Cheat Sheet

Essential Coding Guide for New Ophthalmologists with Cheat Sheet (2024)


What is the new CPT code for ophthalmology in 2024? ›

There is only 1 new Category I CPT code for ophthalmology in 2024: “67516 Suprachoroidal space injection of pharmacologic agent (separate procedure).” This replaces the Category III code “0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication).” The new Category III code that is ...

What pays more, 92012 or 99213? ›

Documentation supports an established level 3 E/M code, 99213 with an allowable of $142.80. The documentation also supports an established intermediate Eye visit code, 92012 with an allowable of $170.10. Which code would you choose? Answer: 99213.

What is CPT code 99213 for ophthalmology? ›

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.

What is the 79 modifier for ophthalmology? ›

Modifier 79 is used to indicate that the service is an unrelated procedure that was performed by the same physician during a post-operative period. Modifier 79 is a pricing modifier and should be reported in the first position. A new post-operative period begins when the unrelated procedure is billed.

What is the CPT code for new patient ophthalmology? ›

Ophthalmology CPT Codes 99201-99215

These codes are for an initial visit to an ophthalmologist or optometrist for a patient who has never seen the physician before. If this person is already a patient of the doctor, then it would be classified as established patient visit codes 99201-99215.

What is the difference between E&M codes and eye codes? ›

The Code Sets Differ

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.

What is CPT code 99214 for ophthalmology? ›

CPT® code 99214: Established patient office or other outpatient visit, 30-39 minutes.

What are the CPT codes for ophthalmology modifiers? ›

CPT code 92025 must be billed with the appropriate modifiers. When billing for both the professional and technical service components, a modifier is neither required nor allowed. When billing for only the professional component, use modifier 26. When billing for only the technical component, use modifier TC.

Which ophthalmology subspecialty makes the most money? ›

Retina Specialists: These professionals who have completed a retina fellowship are often among the highest-paid in the field. They diagnose and treat retinal diseases, perform surgical procedures, and administer treatments like intravitreal injections.

Can you bill 99213 and 99396 together? ›

In this case, the clinician would report the appropriate preventive service visit (such as 99396) on one line of the claim form, followed by the problem-oriented E/M visit (such as 99213) with modifier 25 appended on the next line.

Can you bill 99213 and 52000 together? ›

Answer: Yes, you can bill a cystoscopy (52000, Cystourethroscopy [separate procedure]) and an office visit such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) on the same day as long as the urologist's documentation supports the significant, separately ...

What is modifier 25 in ophthalmology? ›

The CPT definition of modifier –25 is ”Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Its use is indicated when a patient's condition requires a significant, separately identifiable E/M service above and beyond the other ...

What is the ICD 10 code for ophthalmology visit? ›

2024 ICD-10-CM Diagnosis Code Z01. 00: Encounter for examination of eyes and vision without abnormal findings.

Does 99213 need a modifier? ›

If the circ*mstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.

What is the difference between CPT code 99174 and 99177? ›

CPT code 99174 describes the service where data is transmitted to a remote facility. The analysis and report are also compiled remotely. CPT code 99177 describes instrumentation that provides on-site, real-time analysis of the images. This does not require electronic transfer of data for analysis.

What is the CPT code for vision eye exam? ›

CPT Codes 92004, 92014, 92002, and 92012

The comprehensive exam often includes a retinal evaluation and typically is not performed more than once a year. The 92002/92012 eye exam CPT codes are more often used for anterior seg issues or follow-up visits.

What is eye exam CPT code 92004? ›

What is CPT Code 92004. CPT code 92004 is designated for a comprehensive eye examination for a new patient. This includes a general evaluation of the complete visual system.

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