Practice Management Four Misunderstood Concepts of the 92000 Comprehensive Exam Code Definition Mark R. Wright, OD, FCOVD There are four key concepts often misunderstood in the CPT (Current Procedural Terminology) definition Normal General Medical Observation of the 92000 comprehensive ophthalmologic services Y N Body features and symmetry (i.e.: 92004 and 92014). A doctor must understand Y N Appearance these concepts to properly use these codes. These Y N Nutritional state key concepts are: documenting general medical Y N Weight observation, necessity of a dilated fundus exam, Y N Skin color initiation of diagnostic and treatment programs, and Y N Frequency and volume of breaths what and when to bill. Y N Hair distribution Concept #1: Documenting general medical Y N Odors observation The CPT definition for a comprehensive Example 1 ophthalmologic service states: “The service includes history, general medical observation, external and billed. The word “includes” in the definition of 92004 ophthalmoscopic examinations, gross visual fields and and 92014 means always includes. Documentation basic sensorimotor examination.”1 supporting the coding and billing of either 92004 or One piece of documentation often missing in 92014 must include notes about the areas listed in an eye examination medical record coded for 92004 the definition. A primary documentation rule is: if or 92014 is general medical observation. Observing you didn’t write it down, it didn’t happen. To fix this the patient gives significant insight into the general problem, simply add a checklist such as the one in medical health of the patient being examined. Example 1 to your medical examination form. It is Documenting general medical observation involves acceptable to record if each area observed is normal. written notes about areas such as body features and Remember the documentation rule: if you identify a symmetry, appearance, nutritional state, weight, problem, you must further describe it in words skin color, frequency and volume of breaths, hair or pictures. distribution and odors. Without documentation of general medical Concept #2: Is dilation required? observation, 92004 or 92014 cannot be coded or The CPT definition for a comprehensive ophthalmologic service states: “It often includes, as indicated: biomicroscopy, examination with cyclo­ Correspondence regarding this column can be emailed to wright.13@osu. plegia or mydriasis and tonometry.”2 edu or sent to Dr. Mark Wright, OD, FCOVD, 185 S. State St., Westerville, The words “often includes” in the definition for OH 43081. All statements are the author’s personal opinion and may not reflect the opinions of the College of Optometrists in Vision Development, 92004 and 92014 means may or may not include. Optometry & Vision Development or any institution or organization to According to the definition of 92004 and 92014, which the author may be affiliated. Permission to use reprints of this article the doctor must document an ophthalmoscopic must be obtained from the editor. Copyright 2008 College of Optometrists examination; however, a dilated fundus evaluation in Vision Development. OVD is indexed in the Directory of Open Access Journals. Online access is available at http://www.covd.org. (DFE) is optional. This stands in direct opposition to the 99000 Evaluation and Management compre­ Wright M. Four Misunderstood Concepts of the 92000 Comprehen­ hensive examination definition which requires a DFE sive Exam Code Definition. Opt Vis Dev. 2008;39(3):152. unless contraindicated. 152 Optometry & Vision Development Even though coding and billing 92004 and services, consultations, laboratory procedures and 92014 does not require a DFE, the doctor should still radiological services.”5 consider a DFE essential unless contraindicated. The To properly code 92004 and 92014, we need to gold standard for an eye examination is a DFE. In a understand each category of diagnostic and treat­ malpractice lawsuit where something was missed, one ment programs. of the first witnesses the prosecutor will put on the • In order to meet the definition you must initiate stand will be an eye doctor who will be asked “Should a diagnostic or treatment program involving the doctor have dilated this patient?” If something medicine regulated by legislation requiring a was missed, the answer is always, “Yes.” prescription. It is not enough to order over­the­ In a malpractice lawsuit you are not held to the counter medicine for a patient and code 92004 code definition, you are held to the DFE standard. or 92014. The medico­legal issue of a DFE outweighs every • Ordering special ophthalmological diagnostic other consideration. To put this in a context, picture services such as gonioscopy, corneal topography, yourself in a courtroom trying to complete this answer sensorimotor examination, threshold visual field if you missed something retinal that could have been examination or fundus photography meets the picked up on a DFE: “Your Honor, the reason I code definition. There must be a written order for chose not to dilate was ____.” Anything you would the special ophthalmological diagnostic service in put in the blank pales beside what the patient could the primary medical record. potentially lose. • Ordering special ophthalmological treatment It is interesting to note some Medicare carriers such services such as orthoptic and/or pleoptic training, as Palmetto GBA require a DFE for 92004 and 92014. fitting of contact lens for treatment of disease Here’s the relevant quote from the Palmetto GBA or corneal foreign body removal meets the code website for the definition of 92000 comprehensive definition for 92004 or 92014. exams: “A comprehensive examination consists of • In this context, a consultation is a request from you eight or more elements, and always includes a fundus to another physician with expertise in a specific examination with the pupils dilated.”3 Note the medical area beyond your knowledge for advice “always includes” part of the definition. or council in evaluating or treating a patient for Can you do a comprehensive eye exam and not a specific problem. Ordering a consultation meets do a DFE and meet the CPT technical definition the code definition. for 92004 or 92014? The answer is yes. Are you • (Can one optometrist order a consultation from giving the patient the best care and protecting both another optometrist? A strong case can be made the patient and yourself by not doing a DFE? No. It that a “general” optometrist sending a patient to a appears reasonable to conclude if you want to give COVD fellow for advice or council in evaluating the best and safest eye examination in the litigious or treating a patient for specific problem meets society in which we live, it does not make sense to do the definition of a consultation. Because some a comprehensive eye evaluation without a DFE. state optometry laws do not recognize optometric specialties, a consultation request from one Concept #3: Initiation of diagnostic and optometrist to another is a gray area. Ask your treatment programs carrier for clarification in writing.) The CPT definition for a comprehensive ophthal­ • Ordering a laboratory procedure such as a blood mologic service states: “It always includes initiation of evaluation meets the code definition. diagnostic and treatment programs.”4 • (Does ordering spectacle lenses from the laboratory According to the definition, “exam only” with meet the code definition? Since spectacles are not a no additional tests ordered or no treatment program covered medical service unless they are being used prescribed means you cannot code or bill 92004 to treat accommodative esotropia, ask your carrier or 92014. What is the definition of a diagnostic for clarification in writing.) and treatment program? CPT gives us the answer ­ • Ordering corneal pachymetry or an A or B “Initiation of diagnostic and treatment program includes ultrasound meets the radiological services portion the prescription of medication, and arranging for of the code definition. special ophthalmological diagnostic or treatment Volume 39/Number 3/2008 153 When ordering additional diagnostic tests or The doctor is responsible for coding. When the treatment, place the order in your general medical code definition for 92004 or 92014 is not met, a record. Auditors look for a statement of medical different code must be chosen. An intermediate necessity in addition to the medical order for the ophthalmological service (92002 or 92012) or an additional tests or treatment. Put the following appropriate 99000 Evaluation and Management code statement in your general medical record and fill in can be chosen. Understanding these four concepts the blanks to meet both criteria: of the 92000 comprehensive exam code definition The discovery of __ during __ triggered the enables the doctor to code and bill appropriately. medical necessity for ordering __ on __ (insert where, date and time). References 1. CPT 2008 Professional Edition, American Medical Association, p. There are two additional requirements for any 391–392. special ophthalmological services you provide: (A) 2. CPT 2008 Professional Edition, American Medical Association, p. 391. document the additional tests and results on a separate 3. http://www.palmettogba.com/palmetto/providers.nsf/44197232fa85168 piece of paper from your general medical exam record 985257196006939dd/85256d580043e754852573d00071be90?OpenD and (B) write a report. The simplest report has four ocument 4. CPT 2008 Professional Edition, American