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Posted By Amanda on 06-26-2002, 15:49:00 in Ophthalmology
Because 92002 & 92012 is suppose to be used for new or worsening conditions
what would you code for a patient that comes in for a complete eye exam and
everything is done but the patient isn't dilated?

Would you code an E&M and Refraction?

Amanda
Comments (4)
Posted By michael on 06-29-2002, 13:14:00

In a message dated 6/27/02 10:16:22 AM, danderson@med.miami.edu writes:

<< . [NOTE THAT THE GOVERNING RULE IS WHY DID

THE PATIENT MAKE THE APPOINTMENT, NOT WHETHER LATER YOU CAN ELICIT A SYMPTOM

THAT HE REALLY HADN'T NOTED, OR YOU FIND A DISEASE HE DIDN'T KNOW ABOUT.] >>

I agree, except that many patients do make appointments because of symptoms,
but have trouble describing or verbalizing them; or are reluctant to do so,
blaming them on aging, or thinking the symptoms are normal because many of
their same aged friends have them; or thinking that vision is supposed to get
worse, so it's really not something worth mentioning. Many times a patient
will say they are seeing OK, but when asked, will admit they are not seeing
as well as they used to, or don't do this or that as much because of their
vision.
So I don't see a problem with questioning the patient, either by
questionaire, or verbally, about symptoms they are having that may have
contributed to their needing a checkup.
On the other hand, I agree that findings uncovered on exam that is otherwise
routine or screening would not make the visit covered.

Dr. Yaros
Posted By douglas on 06-27-2002, 12:21:00
What is or is not "covered" by a third party may vary according to the
contract the patient has with his third party. This is true for your house
insurance, your car insurance, and your health insurance. We are most aware
of this when you buy the insurance yourself and you have to decide which
coverages you want, how much deductible, etc., and even more aware of it
when you go to use your insurance.

Medicare's contract with its beneficiaries (even though you have not
opportunity to make choices) is pretty specific, that no matter what CPT
code you might be using, statutes and regulations make it clear that
Medicare does not intend to cover screening examinations of any sort (except
for a few specific exceptions like colonoscopy on people with family history
of colon cancer, glaucoma screening on a defined population at particular
risk, and half a dozen more). It does intend to cover evaluation of
symptoms, as well as evaluation and treatment of known problems and
diseases. So if a patient makes an appointment simply for a screening
examination rather than seeking relief from or an explanation of some
symptom, it is simply not a covered service by Medicare. You may tell a
patient that an annual exam is wise for screening purposes, but his
"insurance" (by Medicare) doesn't cover it. He has to decide whether he
wants to take vitamins, exercise at the gym, and have routine physical exams
(eye exams, ear exams, dental exams) - and if so, he pays for these
beneficial actions. They are simply not part of a beneficiary's contract
with the U.S. Government, even if he would like them to be.

Similarly for glasses, and the examination directed toward prescribing
lenses. Doesn't matter if it is stationary refractive error or evolving.
It just isn't a covered service. What is covered is changing medical
condition, like cataract, per the example.

Fine point: If the patient comes in with no complaints, and has an
evaluation of refractive state of the eye and is discovered to have 20/20
vision with present glasses and can't be improved - - it would be hard to
claim this is a covered service under any code. However, if a patient was
motivated to have the exam, not because a year is up since the last exam,
but because he can't see as well - - it then becomes an evaluation of a
symptom (poor vision), which might be due to macular disease, cataract, or
altered refractive state. Because the decision to seek an appointment was
based on a symptom, it is a covered service, even if the cause is found to
be an altered refractive state. [NOTE THAT THE GOVERNING RULE IS WHY DID
THE PATIENT MAKE THE APPOINTMENT, NOT WHETHER LATER YOU CAN ELICIT A SYMPTOM
THAT HE REALLY HADN'T NOTED, OR YOU FIND A DISEASE HE DIDN'T KNOW ABOUT.]
Having determined that the problem is an altered refractive state (for which
evaluation and determination you can use an Eye Code or an E/M code), you
then perform another service - determine exactly the refractive state,
discuss the visual activities of the patient, decide on glasses,
multifocals, progressives, perhaps special computer glasses, recommend
contact lenses, and whether hard or soft lenses, etc., etc. This additional
service is not covered and the itemized bill for this encounter includes two
items: (1) an Eye Code (or E/M code) to evaluate the poor vision, and (2) a
refraction code (which includes all the above - read the introductory part
of the CPT section that includes refraction). Medicare will pay for the
first, and the patient pays for the second if you follow the rules
precisely.

I do not believe the Eye Codes can be used as a way to bypass the statutory
provision which says that Medicare does not cover refractions and does not
cover screening examinations (with a few exceptions, including glaucoma
screening). Having mentioned glaucoma screening, note that it applies only
to those with family history of glaucoma, those with diabetes, and black
patients over age 55. Note also that you use the designated code for the
service, not an E/M code or Eye Code. If you also evaluate a symptom or
disease, you use an Eye Code or E/M code, but do not also bill for the
glaucoma screen, because it is bundled with (included within) the Eye Codes
and E/M codes.

Sue is indeed difficult to reach in my experience. In her defense, I have
learned that she works only as a part-time consultant for the Academy, and
hence limits her time to that for which she was hired/paid. She has another
nearly full time job from what I hear, and her work for the Academy is on
the side. But I don't know the whole story. It is, however, frustrating
for the Academy to imply that coding help is available through her, when the
fact is that there is only limited access.

I have not particular credentials to make the dogmatic statements above, but
I do believe that the scenario above represents the fundamental principles
of Medicare coverage with regard to screening and refraction, and that the
fundamentals are no different for Eye Codes than for E/M codes. The
principles are defined in law. Coding is simply the manner in which the law
is implemented.

Douglas R. Anderson
Posted By Amanda on 06-26-2002, 22:06:00
Thanks but I'm still not convinced. I guess we can do almost what we would
like.

Amanda
Posted By Amanda on 06-26-2002, 19:46:00
But I thought that the condition had to be a new or worsening condition. So
would you say if their refractive state got worse then to go ahead and use
it.

Amanda
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