As a busy optometrist, you need to be thorough with the current procedural terminology (CPT) codes that are used for reimbursement in Medicaid and Medicare. A successful optometrist will need to be conversant with codes falling under the 92 and 99 series so that problems with reimbursement are avoided. Moreover, you need to be wary of the watchful eyes of the Health Care Financing Administration (HCFA), the watchdog that looks out for any sort of misuse.
The code usage will generally depend on what transpires when you see a patient, the time you assign and spend with the patient, and of course, how well the time was spent. If it is just a cursory or even detailed eye exam, with no medical care or any sort of counseling, you need to be using 92 series codes. However, if you do follow that up with counseling, then you need to be using the 99 series codes, though caution is advised while using 99 series codes. Only a seasoned practitioner with a high level of medical expertise should venture into using 99 codes as they require precise documentation at every stage, which is where most optometrists face problems. Whenever you are unsure, it is safer to use 92 series codes while billing.
A regular annual check-up for a patient with chronic diabetes would involve performing a dilated fundus exam, though in reality there is nothing special or different that is done while examining/treating a diabetic. However, an experienced optometrist would carefully scrutinize the retina for tell-tale signs of microaneurysms and/or early stages of retinal edema. As this is an eye exam, it would qualify under 92014 for billing purposes.
Refractions though, need to be billed separately under code 92015 as refractions are classified as separate procedures, hence different from examinations according to the new rules. A word of caution: As annual denotes routine, and since Medicare does not make payments for routine care there may be a legal hurdle for reimbursement.
A follow-up will depend on the clinical findings and may be required if any blot hemorrhages are noticed or retinopathy is detected in the background. In such cases, a follow-up after 6 months may be required. The follow-up should also include checking the patient's diabetes parameters like stability on insulin etc. The billing would be 92014 this time as well. However, if diabetic retinopathy is detected during follow-up, the code that needs to be used is 99214. This is because it is more medical care as it involves counseling and advice on medical problems and qualifies as a level 4 office medical visits.
The above-mentioned points would apply for cataract patients as well. There are specific instances like a patient with a mild cataract who could be pseudophakic in the other eye. In such cases, the codes to be used are 92014 and 92015 as it involves an eye examination and refraction. A patient with a cataract would need a follow-up only after a year or so as it is just minimally symptomatic. However, a patient with a cataract in one eye and who also is pseudophakic in the other needs follow-up after 3 months or even 6 or 12, as the case may be.
Glaucoma patients need to have the intraocular pressure (IOP) checked every quarter or once in 4 months. As the optometrist just does a pressure check and offers counseling on medication it qualifies as level 3, and maybe level 4 medical office visits at times. The code to be used for this again is 99213 and 99214. However, if a patient comes in for a regular quarterly check-up and the optometrist finds that the vision has changed this could mean an eye examination and refraction, which is quite rare though.
Optometry is prone to exposure for malpractice during such times as glaucoma can be easily missed and follow-up is not done, often leading to serious issues like loss of vision. With patients' pressures fluctuating, a visit every two months is necessary to maintain stability. If any deterioration is detected, the optometrist needs to refer the patient to a specialist immediately.
In conclusion, it can be assumed that optometrists need to use office visit codes according to Medicare regulations as they are licensed to do so. Medicare classifies optometrists as physicians based on the services they provide. Hence, any services other than ones relating to specific refraction like ocular disease and its management justifies the use of these codes.