Major changes to eye exam coding have arrived.

On Jan. 1, 2021, the rules we use to select Evaluation and Management (E/M) eye exam codes became much different.

The AMA’s CPT Panel and Medicare have instituted new rules for how we select the level of service for E/M that are vastly different from prior to Jan. 1.

A few important points:

• Eye codes (92002-92014) keep the same rules for coding in 2021, but payment might be lower if Medicare changes them as they have proposed.
• E/M outpatient office-based exam codes (99202-99215) have new guidance.
• Outpatient “Consultation” codes (9924x) and inpatient coding have unchanged guidance for now. They are rarely used in most eye practices.

There are now two methods to code E/M service levels: time and medical decision making (MDM). Either can work for any visit; doctors can switch back-and-forth as needed.

There are significant differences from the way each of these 2021 coding level options have been done. The AMA’s 16-page document (bit.ly/2U7fVz2 ) offers guidelines; Table 2 and the new definitions in this document are particularly helpful.

Time

These new rules are a bit simpler to use, but there are some changes. Providers who offer services personally (either face-to-face or non-face-to-face) get to count time differently as long as it is done on the visit date, although it won’t be the more commonly used of the two methods for code selection in ophthalmology. For example, a recent AMA release (bit.ly/36svSXG ) noted “time-related codes can reflect longer patient encounters that are low on the MDM scale but may involve long periods of time.”

Medical decision making

As noted above, this method will make up the vast majority of how an office visit level is selected. It is made up of three parts: problems, data, and management.

The rules for code selection for a new patient will be the same as for an established one — two of the three areas must meet or exceed the standard (as a practical matter, the lowest level of the three is not considered). Importantly, the exam and the history no longer have specific elements needed for a level of code as they were under the previous rules; each is only required to be “medically appropriate.” As a result, it will be up to the provider to decide what they need for that patient’s history and that patient’s exam.

While we cannot cover the subject in anywhere near the proper depth it deserves, let’s review each part of the MDM:

1. Problems. CPT notes this as “The number and complexity of problem(s) that are addressed during the encounter.” Here, the provider must determine how many problems are being addressed, whether they are acute or chronic, and how bad (severity) each is. Once this is done, a “problem level” is decided upon. It becomes one of the three items in the decision of level of service.
2. Data. CPT notes this as the “... amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.” Data itself is made up of three categories:
   1. Tests, documents, orders, or independent history
   2. Independent interpretation of tests
   3. Discussion of management or interpretation with external provider
   This becomes the “Data level” as the second of the three items.
3. Management. This is noted by CPT as “The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered, but not selected, after shared MDM with the patient and/or family.”

There are four levels of MDM: straightforward, low, moderate, and high. These correspond to exam levels two through five, respectively.

Understand that the payments for eye exams are not stagnant; if an exam can meet an eye code (920xx) and an E/M code, the provider can choose the higher paying of those two.

Summary

Eye coding standards have changed dramatically for some codes but not all. Get “fluent” in the changes and be ready to implement them.

When you can meet the requirements of both an eye code and an E/M code, you might choose differently than you have in the past because of the reimbursement changes.

Lastly, please stay safe and mask up. And, as always, “good coding to you.” OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.