Print | ShareCPT Code: 92012 Region: 37
States covered: General guidelines if your state does not have a local coverage determination
Title: Intermediate Ophthalmological Examination - Established Patient
Category
General Ophthalmological Services
Description
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, established patient, one or more visits
This Medicare carrier does not have a local coverage determination (LCD) for an intermediate ophthalmologic examination. The policy presented is a sample and it is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.
There are two levels of General Ophthalmological Service – Intermediate and Comprehensive.
According to the Current Procedural Terminology Codebook, “intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision-making cannot be separated from the examining techniques used. Itemization of service components, such as slit lamp examination, retinoscopy, tonometry, or motor evaluation is not applicable.”
The intermediate level of service describes an evaluation of a new or existing condition complicated by a new diagnostic or management problem that does not require the intensity of comprehensive services.
Remember, the intensity of a service is a function of medical necessity. The intensity of an eye examination is defined by the number and type of service components that are performed. The decisions regarding examination intensity are based upon the following:
- The clinical judgement of the optometrist or ophthalmologist
- Patient’s medical and ocular history
- The nature of the presenting problem or problems
1. Identification and/or follow-up for Disorders of the Eye and Adnexa
- Disorders of the globe
- Retinal detachments and defects
- Other retinal disorders
- Chorioretinal inflammations, scars, and other disorders of the choroids
- Disorders of the iris and ciliary body
- Glaucoma
- Cataract
- Visual disturbances
- Blindness and low vision
- Keratitis
- Corneal opacity and other disorders of the cornea
- Disorders of the conjunctiva
- Inflammation of the eyelids
- Other disorders of the eyelids
- Disorders of the lacrimal system
- Disorders of the orbit
- Disorders of the optic nerve and visual pathways
- Strabismus and other disorders of binocular eye movements
- Other disorders of the eye
2. Identification and/or follow-up for Infectious and Parasitic Diseases
3. Identification and/or follow-up for Neoplasms
4. Identification and/or follow-up for Endocrine and Nutritional Diseases
5. Identification and/or follow-up for Mental Disorders
6. Identification and/or follow-up for Diseases of the Nervous System and Sense Organs
7. Identification and/or follow-up for Diseases of the Circulatory System
8. Identification and/or follow-up for Diseases of the Skin and Subcutaneous Tissue
9. Identification and/or follow-up for Diseases of Connective Tissue
10. Identification and/or follow-up for Congenital Anomalies of the Eye
11. Identification and/or follow-up for Symptoms, Signs, and Ill-Defined Conditions
12. Identification and/or follow-up for Ocular Injury and Poisoning
13. Identification and/or follow-up for Complications of Surgical and Medical Care
14. Identification and/or follow-up for Conditions Influencing Health Status
- Problems with special senses and other functions
- Organ or tissue replaced by transplant or other means
- States following surgery of the eye and adnexa
- Long-term use of medications
1. Documentation supporting the medical necessity of an eye examination should be legible, maintained in the patient’s medical record, and must be made available to Medicare upon request.
2. This Medicare carrier follows Current Procedural Terminology’s (CPT) documentation requirements for intermediate level services.
GENERAL CPT GUIDELINES
Current Procedural Terminology describes medical eye examinations as General Ophthalmological Services.
Two levels of intensity can be provided – intermediate and comprehensive.
The medical eye examination is divided into nine (9) service components:
- Patient History
- General Medical Observation
- Gross Visual Fields
- Basic Sensorimotor Examination
- External Examination
- Adnexal Examination
- External Ocular Examination
- Ophthalmoscopic Examination
- Initiation or Continuation of Diagnostic & Treatment Program
In addition to these service components, the examination often includes several routine ophthalmologic examination techniques such as keratometry, retinoscopy, tonometry, laser interferometry, exophthalmometry, or Shirmer’s tear testing and may include a fundus examination with the pupils dilated – unless pupillary dilation is medically contraindicated. By definition, these various examination techniques are integrated within the diagnostic evaluation. They should not be coded as separate services.
Initiation of a Diagnosis & Treatment Program can include prescribing medications, lenses, other therapies, arranging further diagnostic test, procedures or treatment services, consultations with specialist, or arranging laboratory and radiological services. It also includes a discussion of diagnostic and treatment options, the condition’s severity, the prognosis, any continuation of diagnostic and treatment plans, any continuation or changes in medications and appropriate follow up visits.
For an intermediate ophthalmological examination, this Medicare carrier’s documentation requirements follow Current Procedural Terminology’s documentation guidelines. Intermediate level services are performed when the clinical circumstances do not require the intensity of a comprehensive examination to determine a diagnosis and treatment plan. The following five (5) service components must be included in the examination to meet the documentation requirements for an intermediate ophthalmological examination:
- Patient History
- General Medical Observation
- Adnexal Examination
- External Ocular Examination
- Initiation or Continuation of Diagnostic & Treatment Program
1. Report an intermediate eye examination for an established patient with CPT code 92012.
2. All of the coverage criteria must be met before Medicare can reimburse this service.
3. The diagnosis code(s) must be representative of the patient’s condition.
4. Services that require less detailed ophthalmologic examination techniques than the General Ophthalmological Services are reported by using the Evaluation and Management Codes.
5. Vision screenings at nursing homes or to a general population is not covered.
6. Refraction is a non-covered service and is not included in a medical eye examination. If the purpose of the office visit is for correction of refractive errors, the General Ophthalmological Service itself is also not covered. When billing for denial purposes, refractive services are reported separately as CPT code 92015.
There are no specific utilization guidelines for intermediate ophthalmological services. In the absence of specific utilization guidelines, eye doctors should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of ophthalmic practice.
Services that exceed the accepted standards of optometric/ophthalmologic practice may be deemed not medically necessary.