CurrentchocchildrenshospitalorangecountyhealthalliancePolicy N/A
Office visits - Routine, Medical and Evaluation & Management Coding
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Governs documentation and reimbursement requirements for routine ophthalmological and E&M office visits submitted to Avēsis on behalf of CHOC Children's Hospital Orange County Health Alliance; affects providers submitting claims for these services.
Policy Summary
Payerchocchildrenshospitalorangecountyhealthalliance
PolicyOffice visits - Routine, Medical and Evaluation & Management Coding
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2022
Last ReviewAug 10, 2022
Next Review DateN/A
Key ActionSubmit sufficient documentation upon request and verify enrollee eligibility for dates of service; physician signature required on chart and procedure notes.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Tables 1 & 2Detailed code-specific documentation requirements
17 subsectionsExam components required
99202-99205,99211-99215E&M codes referenced
Denied if insufficientDenial risk
Coverage and Documentation Requirements
Coverage criteria for routine and E&M ophthalmology visits
Reimbursement is provided when required documentation elements and code‑specific criteria are present; insufficient or missing documentation will result in denial.
ALL of the following
- Provider must document core components for the selected CPT code (history, exam, plan) consistent with AMA/state/NCD/LCD requirements and professional standards of optometry/ophthalmology.
- All required criterion components must be clearly and legibly documented in the patient medical record and made available to Avèsis upon request.
- Physician signature must be present on chart notes, procedure notes, orders, and test interpretations.
- Provider is responsible to verify enrollee eligibility for all dates of service; services for ineligible enrollees will be denied.
- Insufficient documentation or missing components will result in claim denial.
ALL of the following
- Medical/Eye History: chief complaint; significant visual changes; HPI with location and duration; current medications; family/social history.
- Examination components: presenting visual acuity (with/without correction; distance and near); extra‑ocular muscle assessment including cover test (16 in and 20 ft), near point of convergence, versions.
- Gross visual field assessment with method noted (confrontation sufficient unless defect detected); manifest refraction with objective and subjective refraction including best corrected visual acuity at distance and near.
- Adnexa/external exam (lids, lashes; pre‑auricular lymph nodes if indicated).
- Slit lamp anterior segment exam (cornea, conjunctiva); slit lamp anterior chamber (depth, clarity, cell/flare, brief angle assessment prior to dilation); slit lamp lens exam with cataract grading and media clarity.
- Tonometry (unless contraindicated) with method and time notation and IOP recorded.
- Pupillary assessment prior to dilation (size, reaction, presence/absence of APD).
- Posterior segment ophthalmoscopy: time of dilation (unless contraindicated); optic nerve documentation (C/D ratio, appearance, nerve fiber layer); retina documentation (vessels, macula, periphery, vitreous).
- Plan and aftercare: primary diagnosis addressing chief complaint; address other exam findings; treatment plan for all diagnoses (including monitor/follow‑up); final spectacle prescription given (unless medically unadvisable); counseling/coordination of care; summary of care and copy of exam findings provided to patient and referring providers as appropriate.
ALL of the following
- E&M specialty consult codes (Table 2): documentation must meet the code‑specific required elements for the billed E&M code (99202–99205, 99211–99215), including required history/exam elements as medically appropriate, MDM level, and/or time thresholds.
ALL of the following
- For time‑based E&M codes, document 'Time Spent' with specified in‑and‑out times; at least 50% of the documented time must be physician counseling when billing based on time.
- 99204 (New patient): Level of decision = Moderate; Time Spent = 45–59 minutes; Code‑specific documentation must include medically appropriate history/exam and: extensive management options, extensive counseling details, extensive amount of data to be reviewed (old records, labs, imaging), moderate risk of complications/morbidity/mortality, patient aftercare.
- 99205 (New patient): Level of decision = High; Time Spent = 60–74 minutes; Code‑specific documentation must include medically appropriate history/exam and: extensive management options, extensive counseling details, number/complexity of problems and data reviewed, high risk of complications/morbidity/mortality, patient aftercare.
- 99213 (Established patient): Level of decision = Low; Time Spent = 20–29 minutes; Documentation must include history/exam as appropriate, number/complexity of problems, limited data review, low risk of complications, and patient aftercare.
- 99214 (Established patient): Level of decision = Moderate; Time Spent = 30–39 minutes; Documentation must include medically appropriate history/exam, extensive management options, extensive data review, moderate‑to‑high risk, extensive counseling details, and patient aftercare.
- 99215 (Established patient): Level of decision = High; Time Spent = 40–54 minutes; Documentation must include medically appropriate history/exam, extensive management options, extensive counseling details, extensive data review, high risk of complications/morbidity/mortality, and patient aftercare. (Note: some E&M codes may be eligible for post‑service review on a case‑by‑case basis.)
ALL of the following
- Avèsis Medical Directors review submitted documentation against these criteria using medical judgment and may request additional documentation; providers must make records available upon request.
- Some E&M codes may be designated eligible for post‑service review; when designated, reimbursement may be determined after review on a case‑by‑case basis.
Procedure and E&M Codes
Routine ophthalmological CPT codesCPT
| 92002 | Routine ophthalmological exam CPT code (new; intermediate/comprehensive in NE) |
| 92012 | Routine ophthalmological exam CPT code (established; intermediate/comprehensive in NE) |
| 92004 | Routine ophthalmological exam CPT code (new; comprehensive) |
| 92014 | Routine ophthalmological exam CPT code (established; comprehensive) |
E&M specialty consult CPT codesCPT
| 99202 | E&M code (see Table 2 for code-specific documentation, time and MDM requirements) |
| 99203 | E&M code (see Table 2 for code-specific documentation, time and MDM requirements) |
| 99204 | Patient Status = New; Level of Decision = Moderate; Time Spent = 45-59 minutes; Code-specific required documentation components as listed |
| 99205 | Patient Status = New; Level of Decision = High; Time Spent = 60-74 minutes; Code-specific required documentation components as listed |
| 99211 | E&M code (see Table 2 for code-specific documentation, time and MDM requirements) |
| 99212 | E&M code (see Table 2 for code-specific documentation, time and MDM requirements) |
| 99213 | Patient Status = Established; Level of Decision = Low; Time Spent = 20-29 minutes; Code-specific required documentation components as listed |
| 99214 | Patient Status = Established; Level of Decision = Moderate; Time Spent = 30-39 minutes; Code-specific required documentation components as listed |
| 99215 | Patient Status = Established; Level of Decision = High; Time Spent = 40-54 minutes; Code-specific required documentation components as listed (eligible for post service review) |
E&M time thresholds and required MDM/documentation per code
99202Time not listed in Table 2; see policy for code-specific MDM requirements and documentation components
99203Time not listed in Table 2; see policy for code-specific MDM requirements and documentation components
9920445-59 minutes; MDM = Moderate; required documentation: medically appropriate history/exam inclusive of diagnosis, extensive management options, extensive counseling details, extensive data review (old records, physician notes, labs, imaging), moderate risk of complication/morbidity/mortality; patient aftercare; history and exam elements must be documented
9920560-74 minutes; MDM = High; required documentation: medically appropriate history/exam inclusive of diagnosis, extensive management options, extensive counseling details, number and complexity of problems, extensive data review (old records, physician notes, labs, imaging), high risk of complication/morbidity/mortality; patient aftercare
9921320-29 minutes; MDM = Low; required documentation: medically appropriate history/exam inclusive of diagnosis, number and complexity of problems, limited data review (diagnostic and imaging studies), low risk of complication/morbidity/mortality, extensive counseling details, patient aftercare
9921430-39 minutes; MDM = Moderate; required documentation: medically appropriate history/exam inclusive of diagnosis, extensive management options, extensive counseling details, extensive data review (old records, physician notes, labs, imaging), moderate to high risk of complication/morbidity/mortality; patient aftercare
9921540-54 minutes; MDM = High; required documentation: medically appropriate history/exam inclusive of diagnosis, extensive management options, extensive counseling details, extensive data review (old records, physician notes, labs, imaging), high risk of complication/morbidity/mortality; patient aftercare; *Eligible for post service review
Provider Responsibilities and Claims Handling
Documentation Required
Submit records on request and verify eligibility; include physician signature
Submit complete medical records and make them available to Avēsis upon request; verify enrollee eligibility for each date of service. Ensure physician signature is present on chart notes, procedure notes, orders, and test interpretations. Failure to provide sufficient documentation or to confirm eligibility may result in claim denial.
- Provide all required criterion components clearly and legibly in the patient's medical record and produce them when requested by Avēsis.
- Verify and document enrollee eligibility for all dates of service; services for ineligible enrollees will be denied.
- Ensure physician signature is present on chart note, procedure note, orders, and testing interpretation.
Prior Authorization
E&M codes may be subject to post-service review
Certain E&M codes may be reviewed after services are rendered on a case-by-case basis; providers should be prepared to supply requested documentation to support the selected E&M code if notified of a post-service review.
- Some E&M codes (see Table 2 code descriptions and requirements) may be eligible for post-service review.
- If selected for post-service review, supply the medically appropriate history, exam, MDM documentation, and any supporting records cited in Table 2 (e.g., prior records, labs, imaging).
Key Definitions
Medical Decision Making (MDM)
DefinitionMedical decision making (MDM) describes the complexity of establishing a diagnosis and is determined by: number of diagnoses/management options; amount and/or complexity of data to be reviewed; and risk of significant complications, morbidity, or mortality.
Components consideredIncludes evaluation of problems addressed, review and interpretation of data (old records, labs, imaging), and assessment of risk associated with diagnostic procedures and management options.
Use in codingMDM level (Low, Moderate, High) is used with specified E&M codes to justify the code selection and required documentation elements listed in Table 2.
Time Spent (for E&M coding)
Definition'Time Spent' is direct face-to-face physician time with the patient/family; staff or testing time do not apply. At least 50% of the time must be spent on physician-patient counseling for time-based E&M coding.
Documentation requirementTime Spent must specify 'in' and 'out' times to allow accurate calculation of total minutes.
Counseling detailExtensive counseling details may be required in the medical record to support time-based billing when indicated.
Policy Summary
Payerchocchildrenshospitalorangecountyhealthalliance
PolicyOffice visits - Routine, Medical and Evaluation & Management Coding
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2022
Last ReviewAug 10, 2022
Next Review DateN/A
Key ActionSubmit sufficient documentation upon request and verify enrollee eligibility for dates of service; physician signature required on chart and procedure notes.
SourceLink
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