Article Date: 3/1/2009

E/M vs. Eye Codes: Choices for 2009

E/M vs. Eye Codes: Choices for 2009

Part III. Making the choice — which codes should you use?

RIVA LEE ASBELL, Fort Lauderdale, Fla.

Because the ophthalmic practices are the only specialties privileged with the option of choosing between the two sets of codes for outpatient services, optometrists must decide which code is most appropriate for each patient encounter. This decision should be based on three factors: compliance, medical necessity and financial optimization.

As we near the end of the decision-making process, some distinguishing factors should be apparent. Eye codes are vague — there are no sharp divisions between history, examination and medical decision-making. They are all lumped together, whereas the E/M codes are quite specific. For me, the E/M codes are easier to defend under audit.

Eye code examination requirements vary from carrier to carrier. You must have medical necessity for the service itself as well as each examination element that you perform. You cannot decide: "I always bill 92014" twice a year.

There must be medical necessity for the level of service in both sets of codes. The four elements of comprehensive eye code examination and one element of intermediate eye code examination are set by CPT dictate. You have no choice. Thus, there must be medical necessity for each element. In E/M codes you have a choice of elements — it is a quantitative requirement. Any of the elements fulfill the numerical requirement as long as there is medical necessity.

In terms of Medicare coding and reimbursement, compliance means adhering to CMS's regulations and ensuring that your chart documentation supports the code and level of service that you have chosen. Medicare wants you to neither overcode nor undercode. Audits are conducted for both mistakes.

The following factors should guide you in making the final decision: compliance, local and national policies and, finally, financial optimization. There really is no problem in selecting a code that also is remuneratively rewarding.

Code selection

The chart below shows the main codes available for coding office encounters in a non-facility setting. For 2009 there are overall gains compared to the latter half of 2008.

In reality, you probably will only be using five or so of the codes in every day practice. Let's see how the algorithm works.

New Patients/Consultations.

Review Part I and Part II of this series before continuing!

At the end of the day, when you finish examining the patient and your chart documentation is filled out properly, ask yourself "What is my adjective in E/M codes?" If your answer is "low," you are at E/M level 3. If your answer is "moderate," you are at E/M level 4, and if your answer is "high," you are at E/M level 5.

New Patients. If your level is 4 or higher, you should probably be using E/M codes. If your level is 3 or lower, you should be using Eye Codes unless you fail to initiate a diagnostic and treatment program at the comprehensive eye code level. Then you will have to drop to 99203.

Let's look at an example. A patient is examined with complaints of difficulty seeing out of the right eye, etc. A comprehensive history is taken and a comprehensive examination is performed. It is determined that the patient has open angle glaucoma and dry age-related macular degeneration. The adjective is moderate, so you would use CPT code 99204.

The next patient comes in with similar complaints, but has only an early cataract and receives a new prescription for glasses and is told to return in six months. The adjective would be low, so the level is 3. Therefore, comprehensive eye code (92004) is the better choice over the appropriate E/M code (99203).

Consultations. If your adjective is moderate, level 4 or higher, the E/M consultation code should be used. If not, switch to the eye codes.

An example of this is a patient presenting for consultation for opinion and advice concerning possible eye findings related to diabetes mellitus. Once again, a comprehensive history is taken and a comprehensive examination is performed. A diagnosis of early lens changes with no other ocular findings is made. Your adjective is low. The choice is between a consultation and an office visit. This encounter is a consultation and would be at the level 3 — so the code 92004 is more advantageous.

Be very careful before you use the consultation codes. It is a current focus of Medicare audits, and there are strict regulations regarding its use. If someone is not seeking your opinion and advice on the management of a specific issue, the encounter should not be coded as a consultation. Since the consultation codes are E/M Codes, all of the strict chart documentation requirements must be fulfilled.

Return Office Visits:

92012 versus 99213. For return office visits for conditions requiring more frequent visits the choice is often between CPT codes 99213 and 92012. An error was made in the relative value units calculation in 1998, and the erroneous calculation has been pretty much maintained. This has resulted in significantly higher reimbursement for code in 2009 — $9.38 in 2009 on a national average. Given the choice, the eye code pays better than the E/M code and can be used in most instances.

92014 vs. 99214. Code 92014 basically should be used when coding for comprehensive eye examinations and not for follow-up visits for serious disease.

Use 92014 for your follow-ups in which medical necessity dictates a comprehensive examination — such as a return in one year for cataract follow-up. The code is not intended to be used for frequent follow-up visits for serious pathological conditions.

Use 99214 when following serious diseases as long as your medical decision-making is moderate and you have the medical necessity to perform nine of the elements. This code has been a target of OIG investigations and you should be confident of your coding skills and chart documentation when using it.

99212. Most Medicare local coverage determinations for the eye codes mandate that for minimal services code 99212 be used — not 99213 or 92012. Quick check ups for conjunctivitis or healing corneal abrasions would fall into this category.


I hope that this series has provided you with a logical methodology for solving the dilemma when faced with choosing between E/M and Eye Codes. You should be mixing your use of the codes to maintain compliance while optimizing reimbursement at the same time. Good luck! OM

The dollar figures given are national averages. For 2009, the budget neutrality adjuster for the work RVUs is incorporated into the conversion factor. CPT Codes copyright 2008 American Medical Association.

Riva Lee Asbell, a specialist in ophthalmic reimbursement consulting, can be contacted at

Optometric Management, Issue: March 2009