Questions and Answers
What are CPT Codes?
What do office visits get coded under?
Category 1: I or Category 2: VI
What codes are used for Ophthalmology?
92001-92005, 92011-92015
What should you do if you want more in-depth testing, follow-up visits or procedures?
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When can you use a comprehensive eye exam code?
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What does a comprehensive exam entail?
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What is the primary complaint and insurance used for E&M Procedure codes?
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What should you write if you are unable to complete a certain element?
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Chronic or inactive conditions can't fulfill the history requirements.
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What does the level of complexity in exams involve?
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What does MDM stand for?
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Study Notes
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.
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Description
Dive into the essentials of medical coding and billing specifically for optometry with these helpful flashcards. Understand key terms like CPT Codes, Category 1 Codes, and the basics of medical coding practices in eye care. Perfect for beginners looking to grasp foundational knowledge in this field.
