News from the AOA's Blog

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Evaluation and Management (E&M) codes (99201-99215) were introduced for billing office visits in 1992. They are currently used by most health care providers for reporting medical visits. The General Ophthalmological Services (92002, 92012, 92004, 92014) continue to be the codes most commonly used by optometrists and ophthalmologists for reporting eye and vision examinations, in spite of predictions that the E&M codes would replace them.

Many eye doctors favor the E&M codes for reporting medical eye care visits, although the ophthalmological service codes continue to play a major role in reporting eye care visits with and without a medical reason, complaint or presenting problem. It is important to remember that since 1992 the determination of refractive state has not been considered a part of an office visit under either code series. It is a separate service. Refraction has its own code, 92015, and should be reported in addition to the office visit each time it is done.

This key point is clearly defined by Current Procedural Terminology (CPT) and is fully supported by the guidelines included in the Health Information Portability and Accessibility Act of 1996 (HIPAA).

In spite of longstanding, clear guidelines, there is still a fair amount of confusion, as well as potential misinformation, as to which codes should be used for reporting an examination provided for a patient without a medical/ ocular chief complaint. With respect to billing such visits, it is important to remember that it is inappropriate to have separate fee schedules for the same services for different patient groups.

Regardless of the patient’s financial situation, insured or private-pay, insurance guidelines specify that an office must have one distinct fee for each CPT code. Thus once an office has established fees, including for office visits in the 92000 or 99000 series, the office must charge all patients the same fee for the same service, regardless of who is paying the bill. Multiple fee schedules are discriminatory and could lead to reduced reimbursements from carriers if the fee schedules establish a pattern of discounting. In a worst-case scenario, a carrier could determine that an office has been abusive in billing for services and demand a partial or full return of the carrier’s payments to that office.

Enter the S codes

Several years ago, at the request of a third-party payer, the Centers for Medicare & Medicaid Services (CMS) developed two new codes for reporting eye examinations for patients without a medical complaint or reason for their visit. Codes S0620 and S0621 for new and established patients, respectively, are defined as “routine ophthalmogical examination including refraction.”

Even though Medicare participated in the development of these codes, it’s interesting to note that Medicare, Medicaid, other federal health insurance plans, as well as most major medical companies, do not recognize these codes or accept them on their claims.

All codes, including those of the CPT, are a part of the Health Care Procedural Coding System (HCPCS). HCPCS II codes, including S0620-S0621, were developed to identify products, supplies, and services not included in the CPT. HCPCS II codes are used by health care providers to code procedures for which an appropriate CPT code does not exist. Although the vast majority of insurance carriers recognize and respect the codes and definitions of services found in the CPT, carriers are less likely to recognize or accept the level II HCPCS codes. 

The dilemma that many eye care practitioners face is choosing a code for each eye examination while maintaining their fees at appropriate levels for the services they provide. Many doctors worry that if they set their existing examination fees at levels that are appropriate for medical visits the fees may be too high for patients entering without a medical complaint or reason for their visit.

At first glance, the use of S codes might seem to provide an option for doctors to provide a comprehensive eye exam (including refraction) at a reduced fee for such patients. By using the S codes, some doctors are also setting fees for those services at levels different than for the CPT office visit codes, believing the lower fees to be more appropriate to the level of care provided for those patients. While this may sound appealing for doctors with high numbers of patients entering without a medical complaint or reason for their visits, there are other important considerations.

Essentially, doctors provide the same services for visits billed with the S codes as with the comprehensive ophthalmological service plus refraction (CPT 92004 or 92014 plus 92015), while charging less simply because the patient presents without a medical complaint. Most eye doctors consider this to be inappropriate and instead use the 99000 or 92000 office visit, combined with 92015 for refraction, for reporting all their eye examinations.

As with all services, doctors may adjust fees for the services in the 99000 and 92000 series to a level appropriate for both medical and non-medical visits if they feel it is necessary to respond to prevailing fees in their area for services provided for patients entering without a medical complaint or reason for their visit. However, the value of the comprehensive eye examination does not change, regardless of whether the patient presents for “routine care” or “medical care,” with a refractive or medical complaint, or with or without insurance coverage for the service.

The value remains equivalent to the 92000 or 99000 office visit code plus the 92015 for refraction. Charging some patients a lower fee or reporting an alternate code for the same level of service may be unacceptable for many doctors and for many insurers. 

As with all decisions related to the provision of care to patients, it is critical that doctors consider all potential outcomes, pros and cons, before resorting to the use of non-standard, non-CPT codes for reporting that care. This is especially true with codes such as the S codes, which are currently used by only a small minority of eye doctors and are recognized or accepted by very few insurance carriers. Optometrists and their billing staff should periodically review the CPT definitions of office visit codes and the Documentation Guidelines for the Evaluation and Management Services to be sure they are using all CPT codes consistent with their definitions and requirements.

AOA Codes for Optometry ($125, including Current Procedural Terminology, available from the AOA Order Department, 800-262-2210) will provide practices with those valuable resources, as will the free member service AOACodingToday.com, and Web-based AOAReimbursementPlus.com (available to AOA members at a discount). AOA members with questions related to medical records and coding can contact the AOA Clinical and Practice Advancement Group at askthecodingexperts@aoa.org.