Understand Basics of Optometry E/M Coding

Typically, eye care practitioners don’t use the E/M codes for what most Optometry service considers a general eye examination. They are more typically used for patient encounters where the patient presents with a medical complaint or a continuation of medical case management (i.e., glaucoma, allergy, dry eye). The five levels of E/M codes are universally applicable for all manner of disease, yet they are more complicated to apply and require more than one page of chart documentation for a comprehensive examination.

Optometry E/M coding:

So, what’s E/M Coding? The acronym ‘E/M’ stands for ‘evaluation and management. An E/M code consists of five digits. The leading four digits are ‘9920’ for new patients and ‘9921’ for established patients. The fifth digit of the E/M code can range from level ‘1’ to level ‘5’, which directly translates to the level of reimbursement from the insurance. This means the higher the level, the higher the reimbursement.

Generally, E/M coding uses three components:

History, medical decision-making (MDM), and exam. There is also an option to code based on time spent with the patient; however, the time option is less popular and more difficult to track.  For each of the components, the doctor is required to perform and document certain data during the patient encounter. Generally, the more, and the more complex, data is documented, the higher the resulting E/M level.


In the E/M world, history consists of four areas: Chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past family, medical and social history (PFSH) (including medications and allergies). Depending on how much data you document in each of these areas, you end up with a ‘problem-focused, ‘expanded problem-focused, ‘detailed’ or ‘comprehensive’ history for the patient.


MDM consists of three areas: Problem points, risk level, and data points. In order to achieve any E/M level, two out of these three areas must be documented. The overall MDM complexity varies from “straightforward” to “low”, “moderate”, and “high”, depending on the number of problem points, data points, and risk level. The higher the MDM complexity, the higher the E/M level you can achieve for any given encounter.

MDM Complexity Problem Points Risk Level Data Points
Straightforward 1 Minimal 1
Low 2 Low 2
Moderate 3 Moderate 3
High 4 High 4

Problem points:
They are assigned based on the nature of your encounter diagnoses. Their ratings include “self-limited or minor” (1 point), “stable or improving” (1 point), “worsening” (2 points), “new dx with no additional workup planned” (3 points), and “new dx with additional workup planned” (4 points). The more data points, the higher the resulting E/M level. To get to a good number of problem points, document ratings for at least 2 diagnoses, including the primary diagnosis.

Risk levels:
They include “None”, “Minimal”, “Low”, “Moderate” and “High”, where “High” would only be appropriate in complex circumstances where the patient’s life is in jeopardy.

Data points:
These are assigned based on certain tasks or decisions that doctors make to properly treat the patient’s condition(s). For example, the doctor can review or order the patient’s clinical lab results (1 point), review and summarize old patient records (2 points), obtain the patient’s old records (1 point), and/or discuss certain tests with the performing physician (1 point). You can document problem points and risk levels instead. Again, only two out of the three MDM areas need to be met in order to qualify for an E/M code.


You will find a “general” E/M process to assess the exam component, which is based on the procedures and documentation needs of a general physician. However, since providers from different healthcare specialties, such as eye care, vary greatly in their ways to conduct an exam, CMS came up with E/M coding requirements for specialty exams. For eye care, you need to consider fourteen exam elements in determining the correct E/M level: Neurologic, Psychiatric, Aided or unaided visual acuity, Motility (EOM), Intraocular pressure, Confrontation visual field, Adnexa (lids/lashes, lacrimal, orbit, and p. lymph nodes), Bulbar and palpebral conjunctiva, Cornea, Anterior chamber, Iris/pupil, Lens, Dilated evaluation of disc/optic nerve, Dilated evaluation of posterior segment (vitreous, macula, vessels and periphery)

Based on how many of those fourteen exam elements you performed and documented, your exam will be rated as “problem-focused”, “expanded problem-focused”, “detailed” or “comprehensive”.

Exam Elements Exam Rating
1-5 Problem Focused
6-8 Expanded Problem Focused
9+ Detailed
14 Comprehensive

After documenting history, exam elements, and MDM per the above guidelines, you can determine the appropriate E/M code. As mentioned above, the E/M level you can achieve depends on your documentation and on whether the patient is new or established. Below are two tables that summarize the required documentation for history, exam, and MDM for (1) new patients and (2) established patients.

New Patients

Level E/M Code History Exam MDM
1 99201 Problem-focused Problem-focused Straightforward
2 99202 Expanded problem-focused Expanded problem-focused Straightforward
3 99203 Detailed Detailed Low
4 99204 Comprehensive Comprehensive Moderate
5 99205 Comprehensive Comprehensive


Established Patients

Level E/M Code History Exam MDM
1 99211 None None None
2 99212 Problem-focused Problem-focused Straightforward
3 99213 Expanded problem-focused Expanded problem-focused Low
4 99214 Detailed Detailed Moderate
5 99215 Comprehensive Comprehensive High

You might have realized that the E/M coding process can be quite time-consuming and prone to errors. Consequently, a lot of providers tend to under-code or over-code their exams, leaving money on the table or risking insurance audits. So, why not utilize one of the best billing and coding expert available. MBC is doing billing and coding for more than 8 years, to know more about our services contact us at 888-357-3226/ info@medicalbillersandcoders.com