Coding for Eye Exams

The Centers for Medicare & 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 multisystem 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 in 1997. This treatise describes the 1997 Guidelines as they pertain to ophthalmic and optometric examinations. As with many of CMS’s instructions, the guidelines are subject to change.

In addition to E/M codes, ophthalmologists and optometrists may use the ophthalmic visit codes, 92002–92014, 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.

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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