CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and Reimbursement Guideline: Ophthalmology Exams

Guidance on coding, documentation and reimbursement for ophthalmology examinations submitted to Neighborhood Health Plan of Rhode Island; applies to providers submitting CMS-1500 and UB-92 claims.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Ophthalmology Exams

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review Date

Key ActionDocument exam elements and retain notes; notes may be requested to support separate reimbursement of services.

SourceLink

POLICY UPDATE CHANGES

Revision on 9/1/2013 noted as format change and minor edits.

92002-92014Comprehensive exam CPT range

99201-99350E/M CPT range

92225-92284Visual field testing codes

Modifiers listedAccepted modifiers

Ophthalmology Exam Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Ophthalmology Exams

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review Date

Key ActionDocument exam elements and retain notes; notes may be requested to support separate reimbursement of services.

SourceLink

On This Page

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Comprehensive exam includes dilated ophthalmoscopy, motor evaluation, biomicroscopy if indicated, cycloplegia/mydriasis if indicated, tonometry if indicated, and initiation of diagnostic/treatment programs as indicated.

Documented exam elements for a comprehensive exam must include history, general medical observation, external and ophthalmoscopic exam, confrontation visual fields, and basic sensorimotor exam.

ALL of the following

Coding
- Comprehensive eye exam coded with CPT 92002-92014 (general ocular medical examination).
- Non-routine exams billed with E/M CPT codes 99201-99350.
Components of a comprehensive exam may be provided in one visit or on a subsequent day; the date of service reported on the claim must be the date that all components are completed and documented.

Relevant CPTs, Modifiers, and Coding Rules

Relevant CPT/Procedure codesCPT

92002-92014	General ocular medical examination CPT codes for comprehensive eye exam
99201-99350	Evaluation and management CPT codes for non-routine exams
92225-92284	Visual field testing codes (considered unilateral; not reimbursed with -50 modifier)

ModifiersModifier

22,26,32,51,52,53,55,56,57,58	Valid modifiers
59,76,77,78,79,90,99	Valid post-operative modifiers

Date of service for multi-visit components

Date of service ruleThe date of service submitted on the claim must be the date that all components of the comprehensive ophthalmology examination are completed and documented.

Multi-visit allowanceComponents of a comprehensive ophthalmology examination may be provided in one visit or on a subsequent day; billing uses the completion date when all elements are documented.

Documentation requirementAll required exam elements (history, general medical observation, external and ophthalmoscopic exam, confrontation visual fields, basic sensorimotor exam) must be documented to establish completion.

Documentation and Claim Submission Requirements

Documentation Required

Documentation requests

Notes may be requested to support separate reimbursement of services. Maintain complete clinical documentation in the member's medical record to justify the level of service billed. Documentation should include, as applicable: history, general medical observation, external and ophthalmoscopic exam, confrontation visual fields, basic sensorimotor exam, diagnostic/therapeutic plan, and any procedures performed (for example dilated ophthalmoscopy, biomicroscopy, tonometry, cycloplegic or mydriatic examination). Retain any operative or procedure notes, test reports, and correspondence that substantiate separate or additional services. Be prepared to submit copies of these records upon request to validate reimbursement.

Examples of documentation that may be requested: history, exam findings, diagnostic test reports, procedure notes, and treatment plans.
Documentation must support the date of service billed — the date entered on the claim should reflect when all components were completed and documented.

Billing Rule

Claim form applicability

This policy and its billing guidance apply to claim submissions on both the CMS-1500 (professional) and UB-92/UB-04 (institutional) claim forms. Ensure appropriate form, place of service, and provider identifiers are used when submitting ocular exam and related procedure charges. Use the correct CPT/E/M or revenue codes for the form type being submitted and attach requested documentation as directed.

Applies to CMS-1500 and UB-92/UB-04 claim submissions.
When components of a comprehensive ophthalmology exam are provided over more than one day, the date of service on the claim must be the date all components were completed and documented.

Key Definitions

Comprehensive exam

TermComprehensive exam (comprehensive ophthalmology examination)

Included proceduresIncludes intermediate exam procedures plus dilated ophthalmoscopy, motor evaluation, biomicroscopy if indicated, cycloplegia/mydriasis if indicated, tonometry if indicated, and initiation of diagnostic/treatment programs.

Required documentationDocument history, general medical observation, external and ophthalmoscopic exam, confrontation visual fields, and basic sensorimotor exam in the patient record.

CodingUse general ocular medical examination CPT codes 92002-92014 for comprehensive exams.

Non-routine exam

DefinitionNon-routine exam — an exam outside the routine/comprehensive encounter that may require different billing than standard comprehensive exam.

Billing guidanceNon-routine exams may be billed using Evaluation and Management (E/M) CPT codes 99201-99350.

ContextUsed when services provided do not fit within the comprehensive eye exam coding; document services appropriately to support E/M coding.