Monograph - Eye Exams - M11 |
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The Centers for Medicare and Medicaid (CMS), formerly known as the Health Care Financing Administration (HCFA ) has long been concerned with the quality of medical records that document services and procedures reimbursed by the Medicare Program. In 1995, HCFA released documentation guidelines designed to set standards for the use of evaluation and management (E/M) CPT codes (99201-99499). Those original instructions were more readily applicable to multi-system internal medicine-type exams and did not offer much guidance for specialists. After discussions with professional societies, including the American Academy of Ophthalmology, HCFA released new guidelines for single system specialty examinations utilizing E/M codes. This treatise describes these guidelines as they pertain to ophthalmic and optometric examinations. As with many of CMS's instructions, the guidelines are subject to change and it is incumbent upon the practitioner to stay abreast of the changes. Further, local statutes and regulations sometimes impose added restrictions and requirements that are not discussed here.
In addition to E/M codes, ophthalmologists and optometrists may use the ophthalmic visit codes to describe their services. These codes, located in the Ophthalmology section of CPT, describe comprehensive and intermediate levels of service for both new and established patients. Eye care professionals may use either the ophthalmic codes or the E/M codes, as appropriate, to describe their exams.
In this monograph we will walk you through a detailed breakdown of the elements required for both E/M and ophthalmic visit codes. |
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