Optometry offices that screen for, or even treat, medical conditions such as Glaucoma should submit their medical insurance claims with the appropriate medical service code, aka Optometry E/M Coding, for proper reimbursement. The ruling agency for E/M coding is the Centers for Medicare & Medicaid Services (CMS), but other insurances have adopted those same E/M rules.
So, what’s Optometry E/M Coding? The acronym “E/M” stands for “evaluation and management”. An E/M code consists of five digits. The leading four digits are “9920” for new patients and “9921” for established patients. The fifth digit of the E/M code can range from level “1” to level “5”, which directly translates to the level of reimbursement from the insurance. So, generally, the higher the level, the higher the reimbursement. Naturally, it is in the interest of every office to bill on the highest level possible. The question then becomes, how to achieve a certain E/M level? The answer is knowledge of the process of “E/M coding”. This article provides a high-level overview of this process and its specifics for eye care providers.
Generally, E/M coding uses three components: (1) History, (2) medical decision making/MDM, and (3) exam. There is also an option to code based on time spent with the patient; however, the time option is less popular and more difficult to track. Thus, this article focuses on E/M coding based on history, MDM and exam components.
For each of the components, the doctor is required to perform and document certain data during the patient encounter. Generally, the more, and the more complex, data is documented, the higher the resulting E/M level. Let’s take a closer look at each of those components:
In the E/M world, history consists of four areas: (1) Chief complaint/CC, (2) history of present illness/HPI, (3) review of systems/ROS, and (4) past family, medical and social history/PFSH (including medications and allergies). Depending on how much data you document in each of these areas, you end up with a “problem focused”, “expanded problem focused”, “detailed” or “comprehensive” history for the patient. Below is a summary of what that means.
Problem focused | 1 CC and 1-3 HPI elements (i.e., location, quality, severity, etc.) |
Expanded problem focused | 1 CC, 1-3 HPI elements and 1 ROS (i.e., eyes, respiratory, etc.) |
Detailed | 1 CC, 4 HPI elements, 2-9 ROS and 1 PFSH element (i.e., family, medical or social) |
Comprehensive | 1 CC, 4 HPI elements, 10 ROS and complete PFSH |
“Medical decision making” consists of three areas: Problem points, risk level, and data points. In order to achieve any E/M level, two out of these three areas must be documented. The overall MDM complexity varies from “straightforward” to “low”, “moderate” and “high”, depending on the number of problem points, data points and risk level. The higher the MDM complexity, the higher the E/M level you can achieve for any given encounter.
MDM Complexity | Problem Points | Risk Level | Data Points |
Straightforward | 1 | Minimal | 1 |
Low | 2 | Low | 2 |
Moderate | 3 | Moderate | 3 |
High | 4 | High | 4 |
So, what are problem points, risk level and data points?
Problem points are assigned based on the nature of your encounter diagnoses. Problem point ratings include “self-limited or minor” (1 point), “stable or improving” (1 point), “worsening” (2 points), “new Dx with no additional workup planned” (3 points) and “new Dx with additional workup planned” (4 points). The more data points, the higher the resulting E/M level. To get to a good number of problem points, document ratings for at least 2 diagnoses, including the primary diagnosis.
The risk level of any given encounter is highly subjective. Risk levels include “None”, “Minimal”, “Low”, “Moderate” and “High”, where “High” would only be appropriate in complex circumstances where the patient’s life is in jeopardy. So, document the perceived risk level realistically and reasonably. If you would like more guidance on the topic of risk level, you can refer to page 16 in CMS’ E/M guide https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.
Data points are assigned based on certain tasks or decisions the doctors makes to properly treat the patient’s condition(s). For example, the doctor can review or order the patient’s clinical lab results (1 point), review and summarize old patient records (2 points), obtain patient’s old records (1 point) and/or discuss certain tests with the performing physician (1 point). Unless you perform any of these tasks routinely, you may want to skip this MDM area due to the additional labor required. You can document problem points and risk level instead. Again, only two out of the three MDM areas need to be met in order to qualify for an E/M code.
You will find a “general” E/M process to assess the exam component, which is based on the procedures and documentation needs of a general physician. However, since providers from different healthcare specialties, such as eye care, vary greatly in their ways to conduct an exam, CMS came up with E/M coding requirements for specialty exams. For eye care, you need to consider fourteen exam elements in determining the correct E/M level:
1 | Neurologic |
2 | Psychiatric |
3 | Aided or unaided visual acuity |
| 4 | Motility (EOM) |
| 5 | Intraocular pressure |
| 6 | Confrontation visual field |
| 7 | Adnexa (lids/lashes, lacrimal, orbit and p. lymph nodes) |
| 8 | Bulbar and palpebral conjunctiva |
| 9 | Cornea |
| 10 | Anterior chamber |
| 11 | Iris/pupil |
| 12 | Lens |
| 13 | Dilated evaluation of disc/optic nerve |
14 | Dilated evaluation of posterior segment (vitreous, macula, vessels and periphery) |
Based on how many of those fourteen exam elements you performed and documented, your exam will be rated as “problem focused”, “expanded problem focused”, “detailed” or “comprehensive”.
Exam Elements | Exam Rating |
1-5 | Problem Focused |
6-8 | Expanded Problem Focused |
| 9+ | Detailed |
14 | Comprehensive |
After documenting history, exam elements and MDM per above guidelines, you can determine the appropriate E/M code. As mentioned above, the E/M level you can achieve depends on your documentation and on whether the patient is new or established. Below are two tables that summarize the required documentation for history, exam and MDM for (1) new patients and (2) established patients.
Level | E/M Code | History | Exam | MDM |
1 | 99201 | Problem focused | Problem focused | Straightforward |
| 2 | 99202 | Expanded problem focused | Expanded problem focused | Straightforward |
3 | 99203 | Detailed | Detailed | Low |
4 | 99204 | Comprehensive | Comprehensive | Moderate |
5 | 99205 | Comprehensive | Comprehensive | High |
Level | E/M Code | History | Exam | MDM |
1 | 99211 | None | None | None |
2 | 99212 | Problem focused | Problem focused | Straightforward |
3 | 99213 | Expanded problem focused | Expanded problem focused | Low |
4 | 99214 | Detailed | Detailed | Moderate |
5 | 99215 | Comprehensive | Comprehensive | High |
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