An Eye on Coding

January 30th, 2010 - Nancy Maguire
Categories:   Coding   Evaluation & Management (E/M)  
0 Votes - Sign in to vote or comment.

An "Eye" on Coding


Ophthalmology coding is an interesting specialty, especially when it comes to assigning a level of evaluation and management code.  Coders outside this specialty may not realize that there are two sets of codes available to the eye specialist.  The first set is one we are all aware of, codes 99201-99215 for office encounters.  The second set is found in the Medicine section of the CPT® manual and includes codes 92002-92014.  These are termed "General Ophthalmological Services" or GOS codes.

The eye care provider (Ophthalmologist/Optometrist), has the option of using E/M codes or GOS codes as appropriate to medical record documentation.  The E/M series have key components (history, physical, and medical-decision-making), whereas the GOS codes are defined as Intermediate or Comprehensive new or established patient services.

This article will focus on the sometimes conflicting definitions and code descriptions for the GOS codes.  The GOS codes are preceded by "definitions" to define the content of these services.  The "Intermediate" service describes an evaluation and management of a new or existing condition complicated with a new diagnostic or management problem".  It includes history, general medical observation (not eye related, ex, diabetes), external ocular and adnexal examination and other diagnostic procedures as indicated.  The "Comprehensive" service describes a general evaluation of the complete visual system, may require more than one session.  This service includes history, general medical observation, external and ophthalmological examinations, gross visual fields, and basic sensorimotor examination.  It is a bundled service and includes as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry.  It always includes initiation of diagnostic and treatment plan.

If you follow this "definition" guideline for an Intermediate GOS code, 92002 or 92012, the patient must have a new problem or an existing problem with complications requiring management/diagnosis.  Using this logic a patient returning for a Glaucoma check and monitoring, in absence of complaints, will not meet the criteria for assigning a GOS intermediate code.  In this case the provider would assign the appropriate level of E/M code.  

Now if you read the code description listed with 92012 and 92014 you will note a conflict with the "definitions" note.  The established GOS codes state medical examination and evaluation, with initiation or continuation of diagnostic and treatment program.  Given the scenario where a Glaucoma patient is being monitored for pressure checks, the code descriptor does allow for a medical evaluation for continuation of a treatment program.  this variance has caused providers to make a decision on which descriptor they will follow, the note prior to the codes or the code definition itself.  Taking the conservative approach means the provider will need a new problem or a complication of an existing problem to code an established patient GOS code Intermediate level.
Payors have individual guidelines for the use of the GOS codes and their local policies should be reviewed.
Nancy Maguire

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
CMS Expands Telehealth Again
October 20th, 2020 - Wyn Staheli, Director of Research
On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.
Significant COVID-19 Code Changes as of October 6
October 8th, 2020 - Wyn Staheli, Director of Research
Significan COVID-19 Code Changes as of October 6



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association