Eye Codes and apply E/M service

Are you bogged down with Evaluation & Management codes history of present illness (HPI), review of systems (ROS), and exam elements? Financially, you're better off with eye codes rather than E/M services provided of course documentation supports choosing this code. But the following situations will help you ditch eye codes in favor of evaluation &management codes.


To focus on the correct code set, mark these differences so that you don't miss out on the reimbursements.


Does documentation contain the first three key components of E/M i.e. history, examination, and medical decision making (HEM)?


Evaluation & management codes have national coding guidelines that detail the documentation necessary to support a given level of service. The guidelines describe each service level's national Medicare required amount of HEM. Only medically necessary performed and documented items count toward an area. Eye codes do not have those (HEM) requirements and are not subject to mandatory auditing.


Does the note contain enough history?


When determining a service's history level using a standard audit tool, count all medically necessary elements of HPI, review of systems ROS, and past medical family and social/or social history (PFSH).


Does the exam fail carrier's requirements?


If you don't meet your carrier's definition of "immediate" or "comprehensive" eye exams, you should go for an E/M service code instead of an eye code.


Is the patient's problem resolving?


Be careful of using only eye codes if providing comprehensive ophthalmic services that encompass evaluating resolved or resolving conditions that are very straightforward in nature. An E/M code might be the right choice, when documentation describes follow-up of known, straightforward or resolving problems, consultations or hospital services.


Does the visit qualify for time-based billing?


You can use evaluation & management codes for counseling-based visits. When counseling and/or coordination of care dominates more than half the time spent face to face with the patient by the physician, coding guidelines allow you to assign E/M code based on the time indicated in the E/M code's description.


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