Intro to Medical Coding for Optometry Flashcards

Medical Coding and Billing for Optometry

• CPT Codes represent procedures performed during an exam, maintained by the American Medical Association.
• Medical coding in optometry involves categorizing codes for office visits and various procedures.
• Category 1 Codes reflect encounters at hospitals or physician offices and comprise 6 sections.

Categories of Codes

• Category 1: I includes Evaluation and Management codes 99201-99205 and 99211-99215.
• Category 2: VI encompasses codes 90281-99099, 99151-99199, and 99500-99607, which includes ophthalmology codes.
• Ophthalmology codes are specifically designated as 92001-92005, 92011-92015.

Office Visit Coding

• Office visits are typically coded under Category 1: I or Category 2: VI.
• Category 2 codes have an alphabetical character in the 5th digit, measure service performance, consist of 11 sections, and are generally not reimbursed in optometry.

Additional Code Categories

• Category 3 codes pertain to emerging technologies and are infrequently utilized in optometry.

Insurance and Vision Plans

• Vision plans provide coverage for routine ocular wellness exams, including contacts and glasses.
• Health insurance covers medical eye conditions, allowing for unlimited office visits, diagnostic tests, and surgical procedures, often involving co-pays or deductibles.

Coding for Encounters

• Ophthalmology codes should be used if the primary complaint and insurance relate to vision issues.
• A patient's chief complaint must be documented to facilitate reimbursements for subsequent visits.

Intermediate and Comprehensive Exams

• Intermediate New Patient Code: 92002
• Comprehensive New Patient Code: 92004
• Intermediate Established Patient Code: 92012
• Comprehensive Established Patient Code: 92014
• Refraction New Patient Code: 92005
• Refraction Established Patient Code: 92015

Exam Characteristics

• All special ophthalmology codes begin with 920.
• New patient codes have '0' as the 4th digit; established patient codes have '1'. Intermediate exams have a '2' as the 5th digit, while comprehensive exams have a '4'.
• An intermediate visit generally refers to follow-up appointments.

Standards and Examinations

• A comprehensive exam provides a complete evaluation of the visual system, which may not require completion in one session.
• Medicare restrictions prevent using comprehensive eye exam codes.
• Mandatory national standards for comprehensive exams include various history and examination components, encompassing ocular and systemic evaluations.

Review of Systems

• Assessments of the eyes include checking for sudden vision loss, burning or excessive tearing, and redness.
• Review systems expand to other bodily functions like cardiovascular, respiratory, gastrointestinal, neurological, etc., each delineating specific symptoms.

MDM (Medical Decision Making)

• MDM is subjective and challenging to justify; complexity does not equate to time spent with patients.
• Factors include the number of diagnoses, complexity of decision-making, and associated risks.

Complexity Levels in MDM

• Straightforward: Minimal diagnoses and complexity, minimal risk.
• Low Complexity: Limited diagnoses with low risk.
• Moderate Complexity: Multiple diagnoses with moderate complexity and risk.
• High Complexity: Extensive diagnoses and significant risk factors.

History and Examination Documentation

• History and examination levels are categorized as Problem Focused (1-3 elements), Expanded Problem Focused, Detailed, and Complete.
• Ensure to document the rationale if any components cannot be completed during assessments.

Additional Guidelines

• Chronic conditions can fulfill history requirements for annual exams.
• Specific elements in history (HPI) include details on location, quality, duration, timing, context, severity, and signs, while excluding aggravating factors.
• Tobacco use should be documented in packs per year for clarity.

Miscellaneous Patterns

• Coding for problem-focused exams involves minimal elements, while complete exams require in-depth assessments capturing all aspects.
• Unknown information cannot be entered in HPI categories, requiring an explanation for any incomplete elements.