Can a doctor of optometry bill Medicare for a comprehensive eye exam and a procedure on the same day?
The AOA’s coding experts offer guidance to support doctors and staff in providing the best possible patient care while ensuring accurate reimbursements are received.
Here are some recent questions posed to the experts and their answers.
How frequently can a doctor of optometry code CPT 92060 for the same patient?
CPT 92060 is defined as “Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report.” There are no limitations on how frequently doctors can code for CPT 92060 as long as the reason for doing so is medically necessary and properly documented. This is the case for most evaluation and management codes. For CPT 92060, in general, the need for repeat sensorimotor exams is indicated when there is a clear medical necessity based on the progression of the disease, a change in the treatment plan, the presentation of new symptoms and/or findings, or unreliable results from an earlier test. Repeat sensorimotor exams are not expected for a patient who is stable, presents with no complaints, or has a condition that is controlled properly.
What ICD-10 codes are covered for the use of scleral lenses?
HCPCS Code V2531 is defined as contact lens, scleral, gas permeable, per lens, and HCPCS code V2627 is defined as scleral cover shell. While there is no specific “covered code list” that is universal, each HCPCS code is traditionally linked to specific disease entities that are being managed. If the patient is on Medicare, it would only be covered post cataract surgery (ICD-10 Z96.1) per Medicare guidance. If the patient has commercial insurance, the billable diagnosis is outlined in their contracts. Because there are many variations, the doctor of optometry should check directly with the payer about coverage for medically necessary contact lenses.
Can a doctor of optometry bill Medicare for a comprehensive eye exam (CPT codes 92004 or 92014) and a procedure on the same day?
Yes, but this varies with the specifics of a particular encounter. A doctor can bill Medicare for some procedures on the same day they bill either for CPT 92000 (General Ophthalmological Service) or 99000 evaluation and management code. Typically, if the procedure is in the 92015 to 92499 CPT coding range (Ophthalmology Section of CPT), no 25 modifier is applicable. Modifier 25 is used to report an examination service on a day when another procedure was provided to the patient by the same physician or other qualified health care professional. All ophthalmic surgical CPT procedures Eye and Ocular Adnexa (65091-68899), as well as other surgical codes, require the 25 modifier be attached to the examination code. The Modifier 25 is used when the examination service is “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” This is because many procedures are considered to already include the “pre-work” that is required to perform the procedure. For example, if a patient comes in for a glaucoma follow up and trichiasis is discovered during that examination and epilation is performed, the modifier 25 would be required. However, if a patient comes in for a specific complaint of a foreign body sensation, the only code that would be billed for an established patient would be the epilation. Of course, the medical necessity to perform any examination or procedure must be clearly documented in the medical record.
Ask the coding experts
If you have any questions regarding Medical Records and Coding, please submit them by using the Coding Experts Submission Form and one of our coding experts will be in contact with you.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.