Spring hits different this year— one can sense the feeling of renewal and optimism that comes with the rollout of the COVID vaccines and communities reopening. How different from last year. One thing, however, isn’t different. Springtime in the world of eye care brings another feeling: the itch and discomfort of ocular surface disease (OSD).

Beware Allergy Season

OSD is a broad and common presentation in our offices. We often think about dry eye when we hear OSD, but don’t forget that OSD incorporates lid disease as well as other conjunctival and corneal issues. OSD also often occurs with other disease states, such as ocular allergy. When we think about proper diagnosis and treatment of the entire ocular surface, it is critical that our medical record keeping maintains proper detail to support our billings.

Understanding the fundamentals of determining the proper type of medical office visit (920XX or 992XX) is essential for proper medical record compliance and patient management. While some conditions that we treat, such as seasonal allergies, are acute, many are chronic and require continuing care. Set expectations with these patients, as this is not a one- or two-visit process but ongoing management. By most OSD protocols, you may be seeing this patient two to four times per year in addition to their general refractive care.

Proper Protocol

The chief complaint becomes the epicenter of our medical record when coding for ocular surface disease. Keep in mind that the CC must be stated in terms of “complaints or symptoms of an eye disease or injury” to meet the standard of invoking a patient’s medical insurance benefits, and we want to be specific about these signs and symptoms particularly since we may be diagnosing and treating multiple concurrent conditions. If providing a physician-directed return office visit, the CC should be implicit; e.g., “patient returning for physician directed visit secondary to findings consistent with (insert signs and symptoms here).”

Once the CC requirement has been met, then you can proceed with your evaluation. Be mindful that the level of the office visit must be proportional to the level of the disease state. Never assume or code an office visit based upon the patient diagnosis but rather on the medically necessary individual components that you performed. Don’t forget: with the change in 2021 E&M coding rules, you can choose to use either total time or medical decision making to determine the office visit level.

When differentiating between a 920XX code and a 992XX code, a 92012 requires that the patient present with a new condition or an existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. If that isn’t the case, a 992XX code is the way to go. The new E&M code definitions make coding much easier since we have to provide a “medically appropriate history and examination,” but they can complicate the medical necessity requirements since it is now more subjective. 

Personally, I prefer the 992XX codes for medically related eye care visits. Think of them as structure- and function-based coding hierarchy rather than the general overall evaluation a 920XX code provides. Always code each patient encounter by the individual case presentation, as well as the individual patient you are examining and treating, using the choices that you have using either total time or medical decision making as your coding criterion.

When doing ancillary testing, most of the additional tests that you perform will be incidental to the office visit and not separately billable. Measuring tear volume whether by evaluating the meniscus or by Schirmer are not separately billable procedures. Standing orders for clinical lab tests for inflammation (MMP-9) and tear osmolarity are common if the patient has documented signs and symptoms from a qualified questionnaire. However, adjunctive items like photos, lid debridement and meibography must have a clear path of medical necessity established in the record in order for them to be legitimately performed—and don’t forget the interpretation and report requirement with any special ophthalmic testing. 

Diseases that affect the ocular surface can be seasonally acute or chronic, but pollen isn’t the only thing in the air this spring—it’s optimism and opportunity.

Send your coding questions to [email protected].

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.