Federal Service Optometry

Coding Guide v 2.0

CPT Guide

(Note: The descriptions and explanations of these codes are a conglomeration of information from LCD’s available on the web and are intended to provide a general overview rather than definitive policy for the codes)

GENERAL OPHTHALMOLOGIC SERVICES (92002-92014)

DESCRIPTION

There are two levels of general ophthalmologic services – intermediate (92002 New 92012 Established) and comprehensive (92004 New 92014 Established). These codes are appropriate for services to new or established patients when the level of service includes several routine optometric/ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry, and motor evaluation that are integrated with and cannot be separated from the diagnostic evaluation. Itemization of these individual service components is not appropriate. The physical examination elements of an ophthalmologic examination include:

o         visual acuity;

o         visual fields

o         eyelids and adnexa

o         ocular mobility

o         pupils

o         iris

o         cornea

o         anterior chamber

o         lens

o         intraocular pressure

o         retina (vitreous, macula, periphery, and vessels)

o         optic disc

o         mental status

A comprehensive examination consists of nine or more elements and always includes fundus examination – fundus examination does not have to be dilated if dilation is not indicated.  However, if a DFE is indicated but performed on a separate visit (i.e. patient is asked or requests to return for DFE) it is considered part of the initial comprehensive service and should be coded with only a 99499 E&M code and a v72.0 ICD-9 Diagnosis code – not an intermediate exam code.

An intermediate examination consists of eight or fewer of the specified elements. Services that require minimal optometric/ophthalmologic examination techniques are included in the evaluation and management codes (99201 – 99799).

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Refraction (92015)

Refraction is NOT included in the General Ophthalmological Service codes (92002-92014) or the Evaluation and Management Office Visit codes (99201-99215) and should be coded as an additional procedure whenever it is performed.  Refraction refers to the subjective evaluation of refractive error by the provider (or supervised by the provider).  Performing lensometry or auto-refraction does not constitute performing a subjective refraction.  Ordering of spectacles is a separate procedure

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Sensorimotor Examination (92060)

Sensorimotor examination consists of multiple measurement of ocular deviations (e.g.. restrictions or paretic muscle with diplopia) with interpretation and report (separate procedure).

A sensorimotor exam includes measurement of ocular alignment in more than one field of gaze at distance and/or near and inclusion of at least one appropriate sensory test in patients who are able to respond. The findings of the sensorimotor exam should be documented, interpreted and reported by CPT code 92060, separately with E&M 99499 or in addition to the appropriate General Ophthalmologic Service or E/M service provided.

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Orthoptic / Pleoptic Training (92065)

Vision training therapies will are covered under CPT code 92065 (Orthoptic and/or Pleoptic Training, with continuing medical direction and evaluation).

Usage Criteria:

· code training sessions using CPT code 92065

· One unit per visit is allowed

· Visitations limited to three per week

· Duration of therapy must not exceed twelve weeks

· Services must be ordered by a physician and/or an optometrist

· The physician and/or optometrist must document a diagnosis and treatment plan, and must reevaluate the need for continued treatment by the fourth week

· Services may be performed by an optometrist and/or physician

· Staff trained and/or certified in vision training may perform this service only under the direct supervision of an optometrist and/or physician

· Direct Supervision must include documentation of the treatment plan and the re-evaluations completed only by the supervising optometrist or physician. All documentation of services

rendered by opticians or staff trained in vision therapy must be co-signed by the supervising optometrist or physician

·

Medical necessity is valid  for the following diagnoses:

368.00 Amblyopia, unspecified

368.01 Strabismic amblyopia

368.02 Deprivation amblyopia

368.03 Refractive amblyopia

368.31 Suppression of binocular vision

368.34 Abnormal retinal correspondence

367.5 through 367.53

367.5 Disorders of accommodation

367.51 Paresis of accommodation

367.52 Total or complete internal ophthalmoplegia

367.53 Spasm of accommodation

378.00 through 378.9 (For a complete list see ICD 9 CM)

378.00 Esotropia, unspecified

378.9 Unspecified disorder of eye movements

379.57 Deficiencies of saccadic eye movements

379.58 Deficiencies of smooth pursuit movements

also allowable with diagnoses of trauma and CVA.

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Bandage Contact Lens (92070)

Procedure 92070 is an ophthalmological procedure where a disposable, soft or extended wear soft, or a hard contact lens is fitted by the physician to treat a diseased or injured eye.  Common uses are corneal abrasions (918.1) and Keratoconnus (371.62).  Documentation should include indication for use, all lens parameters, use instructions and all follow-up.

Use of code 92070 is indicated for the following diagnoses:

05321 Herpes zoster keratoconjunctivitis

05443 Herpes simplex disciform keratitis

3510 Bell's palsy

36032 Ocular fistula causing hypotony

36034 Flat anterior chamber

36722 Irregular astigmatism

37000 Corneal ulcer, unspecified

37006 Perforated corneal ulcer

37007 Mooren's ulcer

37020 Superficial keratitis, unspecified

37021 Punctate keratitis

37023 Filamentary keratitis

37033 Keratoconjunctivitis sicca, not specified as Sjögren's

37034 Exposure keratoconjunctivitis

37035 Neurotropic keratoconjunctivitis

37120 Corneal edema, unspecified

37123 Bullous keratopathy

37142 Recurrent erosion of cornea

37143 Band-shaped keratopathy

37152 Other anterior corneal dystrophies

37157 Endothelial corneal dystrophy

37162 Keratoconus, acute hydrops

37172 Descemetocele

37400 Entropion, unspecified

37410 Ectropion, unspecified

37515 Tear film insufficiency, unspecified

7102 Sicca syndrome

8710 Ocular laceration without prolapse of intraocular tissue

9181 Superficial injury of eye and adnexa; cornea

9300 Corneal foreign body

9402 Alkaline chemical burn of cornea and conjunctival sac

9403 Acid chemical burn of cornea and conjunctival sac

V425 Organ or tissue replaced by transplant, cornea

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Scanning Laser Glaucoma Tests (SLGT) (92135)

Procedure Description

92135 Scanning computerized ophthalmic diagnostic imaging ( e.g. scanning laser) with interpretation and report, unilateral, a.k.a. Confocal laser scanning

ophthalmoscopy (topography) or scanning laser polarimetry (nerve fiber analyzer) Confocal laser scanning topography uses videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina. Scanning laser polarimetry measures change in the linear polarization of light (retardation). It uses a polarimeter, an optical device, to measure linear polarization change and scanning laser ophthalmoscope together to measure the thickness of the nerve fiber layer of the retina.  Although these techniques are different, their objective is the same. It allows for early detection of glaucoma damage to the nerve fiber layer or optic nerve of the eye and to follow patients with glaucoma for signs of progression.  Scanning laser glaucoma tests discriminate among patients with normal intraocular pressures who have glaucoma, patients with elevated intraocular pressure who have glaucoma, and patients with elevated intraocular pressure who do not have glaucoma. Medicare covers scanning laser glaucoma tests (SLGTs) when medically necessary and reasonable to diagnose early glaucoma; monitor glaucoma treatment; and differentiates causes of other optic nerve disorders when a diagnosis is in doubt. Medicare will allow SLGT when visual field results are insufficient to properly diagnose and manage the patient.s condition. Suggested guidelines for the use of scanning laser glaucoma tests follow:

·          Once per year would be appropriate to follow glaucoma suspect patients or those with mild glaucomatous damage characterized by any or all of the following:

o         Intraocular pressure >22mmHg as measured by applanation

o         Symmetric or vertically elongated cup enlargement, neural rim intact, cup to disc ratio >0.4

o         Focal optic disc notch

o         Optic disc hemorrhage or history of optic disc hemorrhage

o         Nasal step or small paracentral or arcuate scotoma

o         Mild constriction of visual field isopters

·          Patients with moderate glaucomatous damage may be followed with medically necessary SLGT or visual fields. When SLGT is used, patients typically receive one test each per year. Moderate glaucomatous damage is characterized by any or all of the following:

o         Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio >0.5, but <0.9

o         Definite focal notch with thinning of the neural rim

o         Definite glaucomatous visual field defect, e.g., arcuate or paracentral scotoma, nasal step, pencil wedge, or constriction of isopters

·          In advanced glaucomatous damage when the nerve fiber layer has been extensively damaged, visual fields will likely detect changes and would be preferred over SLGT. SLGT would rarely be beneficial and is not indicated unless reasonable and necessary visual field testing cannot be reliably performed. Advanced glaucomatous damage is characterized by any or all of the following:

o         Severe generalized constriction of isopters (i.e., Goldmann 14e <10 degrees of fixation)

o         Absolute visual field defects within 10 degrees of fixation

o         Severe generalized reduction of retinal sensitivity

o         Loss of central visual acuity, with temporal island remaining

o         Diffuse enlargement of optic nerve cup, with cup to disc ratio >0.8

o         Wipe-out of all or a portion of the neural retinal rim

The primary diagnosis for SLGT must support that the service is reasonable and necessary for the diagnosis or treatment of illness or injury. The diagnosis must be present for the procedure to be coded.  Documentation must show that the service was reasonable and medically necessary for that diagnosis.  If a scanning laser glaucoma test is performed, it will affect the medical necessity for other services used to evaluate glaucoma. You must describe and document the medical necessity for procedures such as fundus photography or extended ophthalmoscopy clearly and legibly in the patient.s record. SLGT is not medically necessary for those patients who do not meet the criteria above.

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Color Vision examination, extended (92283)

Use this code when you see a patient specifically for an in-depth color vision examination.  Use of this code requires a higher level diagnostic test than PIP or Isihara plates (which are included in the E&M and General Ophthalmologic Service Codes).  Valid diagnostic test include the Anomaloscope, D-15 Test, and the 100 Hue Test. 

Documentation:  History should document the reason for the extended testing.  Exam should report all findings, interpretation and diagnosis.

Valid Dx codes for use:

368.51   Protan defect in color vision

368.52   Deutan defect in color vision

368.53   Tritan defect in color vision

368.54   Achromatopsia

368.55   Acquired color vision deficiencies

368.59  Other color vision deficiencies

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Contact Lens Services (92310, 92325, 92326)

Contact Lens Fitting (92310) - This code applies to new fits, refits, and updates of current CL prescriptions as long as the following conditions are met:

o         Documented K readings in record

o         Documented all relevant contact lens prescription information in record

o         Documented wear and care instructions in record (i.e. – Dw vs EW, care system, disposal times, hours per day, etc.)

o         Document that pt. was instructed to RTC with any problems 

o         This code includes classes on insertion and removal if required

                     Note: Follow-up services to insure the fit is good are included in this code.

Modification of Contact Lens (92325) – This code applies when you polish or modify the parameters of an RGP lens using a contact lens modification instrument – this is a unilateral service – use modifier 50 if done bilaterally

Replacement of Contact Lens (92326) – This code applies when dispense a lens from stock to replace a lost or damaged lens

ICD-9:  These codes should be linked to the appropriate Refractive Error code when used

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Fitting of Spectacles, non-aphake (92340 (mono), 92341 (bifocal), 92342 (multifocal))

These codes cover the service of Fitting and Ordering of spectacles to include all measurements and recording of Lab specifications (SRTS or SRTS II).  Dispensing of the spectacles (by mail or in-person) is included in the service.

Coding tips:

·          If done on the same day as the examination the code should be used by the examining doctor with the technician as an additional provider (Para-professional) associated with the service.

·          If spectacles are fit/ordered on a separate visit, or on a walk-in with an Rx from another clinic or from lensometry of current glasses, these codes can be used by the technician as a visit under their name.  In this case the following applies:

o          E&M 99499

o         CPT 92340, 92341, or 92342 as appropriate

o         ICD-9 will be the relevant refractive error from the Rx

o         This service by the technician must be documented in the record if it is to be coded as a visit.

Repair and re-fitting of Spectacles (92370)

This code applies to the re-fitting (adjustment) or repair of an exiting pair of glasses.  It normally would involve only the technician and would be coded as noted in the second example above, except using 92370 as the CPT code.  If the service is done for a patient when they are in the clinic for a routine exam it should be reported as in the first example above.

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Visual Function Screening, Quantitative (99172), Screening of Visual Acuity, Quantitative (99173)

CPT 99172: Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudo-isochromatic plates, and field of vision (may include glare and/or contrast sensitivity testing)

·          This code is normally used by technicians when coding visits for screenings or physicals that require more than just a visual acuity.  It can be performed using an exam or screening room and/or a screening device (e.g. – Titmus Vision Tester).   Normally this code is not used by the doctor with the exception of school screenings.

·          Coding tips:

o         E&M 99499

o         CPT 99172

o         ICD-9 should be the relevant v70.5 x code (reason for screening or physical)

CPT 99173: Screening test of visual acuity, quantitative, bilateral

·          This code is normally used by technicians when coding visits for screenings or physicals where only a visual acuity is required.

·          Coding tips:

o         E&M 99499

o         CPT 99172

o         ICD-9 should be the relevant v70.5 x code (reason for screening or physical)

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Removal of FB, external eye, conjunctiva, superficial (65205), embedded (65210)

Removal of FB, external, cornea without Slit lamp (65220), with Slit lamp (65222)

These codes are used when FB’s are removed form the cornea or conjunctiva:

·          For the conjunctiva use:

o         65205 – Superficial: If the FB is simply lifted off c a needle, spud, cotton-tip applicator or forceps

o         65210 – Embedded: If the conjunctiva must be incised to remove the FB – note that use of this code implies no repair of the conjunctiva is required – a pressure patch and/or broad spectrum antibiotic may be applied following the procedure

o         Applicable ICD-9 codes

§          918.2  Superficial injury of the conjunctiva

§          918.9  Other and unspecified superficial injuries of the eye

§          930.1  Foreign body in conjunctival sac

§          930.8  Foreign body in other and combined sites on external eye

·          For the cornea use:

o         65220 – without slit-lamp

o         65222 – with slit-lamp – may or may not require incising the corneal tissue - a pressure patch and/or broad spectrum antibiotic may be applied following the procedure

o         Applicable ICD-9 codes:

§          918.1  Superficial injury of cornea

§          918.9  Other and unspecified superficial injuries of the eye

§          930.0  Foreign body in cornea

§          930.8  Foreign body in other and combined sites on external eye

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Scraping of cornea for smear or culture (65430)

·          Use this code if a scraping is done for a laboratory culture – must link to an appropriate diagnosis such as corneal ulcer, herpes, specified keratitis, etc.  Be sure to document the process in the notes as well as what cultures were ordered from the lab.

Removal of corneal epithelium (debridement) (65435)

·          Use this code when the cornea is debrided (corneal epithelium removed for therapeutic purposes)– the most common use would be in treatment of recurrent corneal erosion but other diagnoses may support medical necessity.  Be sure to document the procedure as well as anticipated benefit and necessary follow-up.

Anterior Stromal Puncture (65600)

·           

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Treatment of Trichiasis – Epilation by forceps (67820)

Triciasis is the condition in which inversion of eyelashes rub on the cornea, causing a continual irritation. Epilation may treat this complication. The following CPT code is appropriate to use when extraction of the lashes is the performed:

67820 Correction of trichiasis; epilation, by forceps only.

Please note, this code is intended to be billed per eye. Do not use the above code per eyelid or per eyelash.

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Lacrimal Punctum Plugs (68761)

CPT code 68761 identifies the closure of a single punctum; therefore the relative value units for this procedure are set up for each punctum.
Bilateral coding rules apply to this procedure if performed on both eyes. If one punctum is closed in each eye, report the procedure code with a 50 modifier.

In situations where two puncta are treated in the same eye, multiple surgery rules apply. In this case, report each service as a separate line item, adding the 51 modifier to the second and subsequent procedures.

If multiple puncta are closed in each eye, both bilateral payment and multiple surgery rules apply. For example, if two puncta are closed in each eye, report the closure of the first puncta in each eye with the procedure plus the 50 modifier. The closure of the second puncta in each eye should be reported with both bilateral and multiple surgery modifiers, i.e. the procedure with a 50 and 51 modifier.

Separate coding is allowed for A4263 (permanent, long term, non-dissolvable lacrimal duct implant), when performed in an office setting. These plugs are not subject to either bilateral or multiple surgery reductions and should be reported without modifiers but with an indicator in the number of services field.

Normally the following procedure code will also be used (68801 Dilate tear duct opening) as part of the plug insertion procedure

Dry Eye Syndrome Defined

Dry eye syndrome is generally characterized by tearing, mucus discharge, blurred vision, itchy, red eyes, gritty sensations, burning, photophobia, or frank eye pain. Dry eye syndrome is a chronic condition and usually irreversible. It is an ocular surface disease secondary to inadequate lubrication.

Indications for use:

Punctum closure is valid for moderately severe to severe dry eye syndrome.

Documentation:

The physician documentation must indicate that intensive topical eye therapy and medical management have failed and/or the patient has superficial punctate keratitis, corneal thinning, ulceration or perforation or

dry eye syndrome associated with certain medical diseases such as connective tissue disease. The documentation must also support that diagnostic testing conclusively supports dry eye syndrome and that local eye therapy has been tried and found to be ineffective prior to placement of punctum plugs.

Testing:

Dry eye symptoms are more important than tear function or volume tests; however, Schirmer’s test, Rose Bengal Staining, or fluorescein staining may be helpful in diagnosis. Temporary punctum closure by means of collagen plug implant will not be considered a diagnostic test for dry eye syndrome, but will be considered as a means in which to determine if permanent punctum closure will be effective treatment for moderately severe to severe dry eye syndrome.

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Corneal Topography (S0820)

S0820 is an HCPCS code.  It can be found on CHCSII by searching under the procedures tab in the A+P screen with the HCPCS button on (located below the search box).

This procedure may be coded as a unilateral code except the technical component may be coded only once, even if the procedure is performed bilaterally.

Indications for use:

Use of the code for corneal topography will be allowed as a separate procedure when associated with one of the following indications:

o         postoperative cataract extraction, penetration keratoplasty, lamellar keratoplasty, refractive keratoplasty with acquired astigmatism, LASIK, PRK

o         preoperative evaluation or irregular corneal curvature for intraocular lens power determination or refractive surgery

o         identification and follow-up for corneal disease causing irregular astigmatism - keratoconus, pterygium, peripheral corneal degenerations (Mooren’s ulcer, Terrien’s degeneration)

o         iatrogenic corneal astigmatism-surgically induced, trauma induced, corneal distortion from contact lens wear; or, unexplained visual loss thought to be due to irregular corneal astigmatism.

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