billing question

I work for an optometrist office. We use exam writer that gives the E&M code (exam level) based on the elements documented.



My question is when billing a level 4 like a 99204 or 99214 sometimes we only have a refractive diagnosis (example 367.1, 367.0, 367.20).



When billing Medicaid am I billing correctly using these codes? Claims have been paid billing in this way .I have tried to research but have not been able to find black and white answer.

re: billing question

The question you must ask is medical necessity for doing a level 4 exam for a refractive diagnosis.
The following ICD-9 diagnosis and CPT® codes will be considered a routine vision (eye) examination. ICD-9 diagnosis codes: V72.0, 367.0, 367.1, 367.20, 367.21, 367.22, 367.31, 367.32, 367.4, 367.51, 367.52, 367.53, 367.81, 367.89, and 367.9 when billed as the primary diagnosis and in conjunction will the following CPT® codes: 92002, 92004, 92012, and 92014.
Why are you using the E/M codes when you have the eye codes?
Medicaid has its own rules per state but a 99204 or 99214 seems excessive based on diagnosis codes.

re: billing question

Be very careful with E/M "Advisors" or "Calculators" or any program that assigns an E/M code.

They are only as good as the programming and sometimes the programming is not good.

I am not discussing any specific software.

re: billing question

I agree that one must be very careful in using any software suggested code levels. I have tested some that are inaccurate. Some very real concerns from physicians is that there is no accurate accountability for the MDM portion of the encounter, or any consideration of medical necessity. Regardless of any software system, in a payer audit, the provider is responsible for proper billing and accurate E & M levels. It really is "buyer beware". I have worked on a number of payer audits, and have never seen any case where software systems were considered a valid argument for erroneous coding & billing.