An Eye on Coding

An "Eye" on Coding

Ophthalmology coding is an interesting specialty, especially when it comes to assigning a level of evaluation and management code.  Coders outside this specialty may not realize that there are two sets of codes available to the eye specialist.  The first set is one we are all aware of, codes 99201-99215 for office encounters.  The second set is found in the Medicine section of the CPT® manual and includes codes 92002-92014.  These are termed "General Ophthalmological Services" or GOS codes.

The eye care provider (Ophthalmologist/Optometrist), has the option of using E/M codes or GOS codes as appropriate to medical record documentation.  The E/M series have key components (history, physical, and medical-decision-making), whereas the GOS codes are defined as Intermediate or Comprehensive new or established patient services.

This article will focus on the sometimes conflicting definitions and code descriptions for the GOS codes.  The GOS codes are preceded by "definitions" to define the content of these services.  The "Intermediate" service describes an evaluation and management of a new or existing condition complicated with a new diagnostic or management problem".  It includes history, general medical observation (not eye related, ex, diabetes), external ocular and adnexal examination and other diagnostic procedures as indicated.  The "Comprehensive" service describes a general evaluation of the complete visual system, may require more than one session.  This service includes history, general medical observation, external and ophthalmological examinations, gross visual fields, and basic sensorimotor examination.  It is a bundled service and includes as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry.  It always includes initiation of diagnostic and treatment plan.

If you follow this "definition" guideline for an Intermediate GOS code, 92002 or 92012, the patient must have a new problem or an existing problem with complications requiring management/diagnosis.  Using this logic a patient returning for a Glaucoma check and monitoring, in absence of complaints, will not meet the criteria for assigning a GOS intermediate code.  In this case the provider would assign the appropriate level of E/M code.  

Now if you read the code description listed with 92012 and 92014 you will note a conflict with the "definitions" note.  The established GOS codes state medical examination and evaluation, with initiation or continuation of diagnostic and treatment program.  Given the scenario where a Glaucoma patient is being monitored for pressure checks, the code descriptor does allow for a medical evaluation for continuation of a treatment program.  this variance has caused providers to make a decision on which descriptor they will follow, the note prior to the codes or the code definition itself.  Taking the conservative approach means the provider will need a new problem or a complication of an existing problem to code an established patient GOS code Intermediate level.
Payors have individual guidelines for the use of the GOS codes and their local policies should be reviewed.
Nancy Maguire

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