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Posted By Amanda on 09-19-2006, 16:34:00 in Ophthalmology
If a 65 yr old patient came in with a chief complaint of decrease distance VA and HPI stating hard to read road signs and also has noticed a FB Sensation in the left eye.

My 1st question is shouldn't the doctor mention the FB Sensation during his exam somewhere?

Also he checks their vision which is 20/25, everything is normal except Brow Ptosis, 1/2 NS Cataract, and PC IOL. His impression states Refractive Error and NS, right eye.

What diagnosis would you use. The refractive error or the NS?

Thanks!

Amanda
Comments (15)
Posted By michael on 10-04-2006, 18:10:00

In a message dated 10/3/2006 9:26:50 A.M. Eastern Standard Time,
dagmd@comcast.net writes:

If you look at the CPT manual, the description of a "comprehensive
ophthalmological sevice" states that it "always includes initiation of
diagnostic and treatment services." If you have done a complete exam, I
suppose you could have performed enough elements of the exam to satisify the
diagnostic requirements...but if the only thing wrong is a refractive error,
then no treatment is required. Or do you consider prescribing of eyeglasses
to be a treatment? If so, I personally think that, if a level 4 eye exam is
supposed to be roughly equivalent to a level 4 or even 3 E&M, then it is
quite a stretch to equate a routine exam with nothing wrong with the patient
(other than a refractive error, considering that a "screening" exam on a
patient is not even a covered service under medicare rules) considering all
the requirements there are to justify a level 3 or 4 E&M code.

Do other members of the list also use 92004 or 92014 CPT codes for routine
exams with nothing wrong but a refractive error? It would be interesting to

get a feel for how common this practice is.

D. Greenfield, M.D.

If a patient presents with a symptom, and no pathology is found, you can
code for Medicare for the symptom. The level depends on how much of an
evaluation you did, including history, exam, MDM for E/M, or the requirements for the
eye codes. You probably wouldn't use a 99214 if there was no pathology, but
you could use the comprehensive eye code if you had to do a full dilated exam,
and initiated some treatment, even tears or glasses.

Dr. Yaros
Posted By Rita on 10-03-2006, 12:41:00
Yes, we do consider prescribing of eyeglasses to be treatment.
Complexity of medical decision making is not a factor with the eye
codes. The most use of the eye codes is associated with vision plans in
our practice which require the elements listed for a comprehensive exam.
Most of our Medicare patients have some type of age related medical
problem.

Rita Knapp, CPC
Chief Compliance Officer
Senior Billing Specialist
Direct (317) 573-0756
Fax (317) 846-6063
rknapp@abramseyecare.com
Posted By michael on 09-22-2006, 02:23:00
In a message dated 9/20/2006 5:34:38 P.M. Eastern Standard Time,
vpassaro@med.miami.edu writes:

You go with the blurry vision.

Vivian

This is correct, but don't overuse blurred vision. Use it only when there is
no other possibility of another diagnosis. sometimes there is a refractive
change but a little cataract, AMD, tearing, or dry eye etc. that might
contribute something as well. Then go with the other diagnosis, even if refractive
error seems to be the major cause. The overuse of blurred vision might draw
attention.

Dr. Yaros
Posted By vivian on 09-21-2006, 11:49:00
When you truly have a Routine, Annual, Regular Ck-Up, My dog ate my
glasses, etc.

Vivian Passaro, CPC
Compliance Program
Department of Ophthalmology
University of Miami School of Medicine
Tel: 305-326-6383
e-mail: vpassaro@med.miami.edu
Posted By Amanda on 09-20-2006, 20:05:00
So when would you have to bill using refractive error?

Amanda
Posted By Amanda on 09-20-2006, 20:04:00
Thanks!
Posted By vivian on 09-20-2006, 18:47:00
You go with the blurry vision.

Vivian
Posted By james on 09-20-2006, 18:33:00
We bill 92014, complete exam eye code.

Jim Kendrick, COA
Posted By Rita on 09-20-2006, 18:11:00
File it with the symptom - blurry vision 368.8 & make sure the HPI says
"pt complains of blurry vision".

Rita Knapp, CPC
Chief Compliance Officer
Senior Billing Specialist
Direct (317) 573-0756
Fax (317) 846-6063
rknapp@abramseyecare.com
Posted By Amanda on 09-20-2006, 16:42:00
So when our elderly patients come into the office with only a cc of decreased vision/blurry vision, we do a complete exam, and the only thing wrong with the patient is refractive error...

what do you do?

Amanda
Posted By vivian on 09-20-2006, 15:28:00
You are essentially correct. If you have no bottom line dx, you use
blurry vision. That's why the patient came to see the doctor.
There is actually a special section in the Medicare manual regarding
ophthalmology and coding is driven by the reason for the visit (which
can be signs, symptoms) unless you can end up with a definitive
diagnoses DIRECTLY related to why the patient came in (CC), except for
refractive errors. If the patient came with decreased vision and you
end up with Normal Eye Exam, or Presbyopia, or any of the "opias", you
use the reason for the visit on the claim. We are somewhat of an
exception. That is why it is SO SO important to elicit a very good
Chief Complaint. If you have something like "I need new glasses",
"Annual follow-up", "Routine exam" and the like, STOP and let the
patient know it is a self pay exam, or to a vision plan. Patients
sometimes think they can't see because their Rx is no good anymore -
even when they are having a retinal detachment.

Vivian Passaro, CPC
Compliance Program
Department of Ophthalmology
University of Miami School of Medicine
Tel: 305-326-6383
e-mail: vpassaro@med.miami.edu
Posted By Amanda on 09-20-2006, 13:52:00
Anytime a Medicare age patient comes into the office with decreased vision is it okay to use blurry vision vs. Refractive Error. I thought we could only do that if there wasn't an explanation for the blurry vision?

Amanda
Posted By Rita on 09-19-2006, 19:14:00
The decrease in vision points to the NS. I would use the NS unless the
pt has a vision plan that they wish to use.

Rita Knapp, CPC
Chief Compliance Officer
Senior Billing Specialist
Direct (317) 573-0756
Fax (317) 846-6063
rknapp@abramseyecare.com
Posted By vivian on 09-19-2006, 18:09:00
Is the decreased vision and hard to read signs due to the NS cataract?
If so, use the NS Cat code. If not, use the decreased/blurry vision.
And yes he should address all of the patient's complaints. The FB
sensastion could be dryness.

Vivian Passaro, CPC
Compliance Program
Department of Ophthalmology
University of Miami School of Medicine
Tel: 305-326-6383
e-mail: vpassaro@med.miami.edu
Posted By David on 09-19-2006, 17:49:00
Well a diagnosis of refractive error usually puts the exam into routine.
You will probably want to use any and all the medical diagnosis.
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