By Stephanie Adams Ophthalmology Coding
Understanding the distinction between 99 codes and 92 codes is critical for correct medical billing, especially in eye care and optometry. These codes represent two fundamentally different approaches to documenting and billing patient visits, each with its own criteria, use cases, and implications for reimbursement.
Overview of 99 and 92 Codes
99 Codes (Evaluation & Management, or E/M Codes)
- Codes range: 99202-99205 (new patients), 99212-99215 (established patients).
- Purpose: Used for medical visits requiring evaluation and management – these focus on medical decision-making and/or total time spent on the date of the encounter.
- Application: Typically used when the visit addresses medical eye conditions such as glaucoma, cataracts, retinal diseases, or systemic illness with ocular implications.
- Documentation: Requires medically appropriate history and/or exam, and determines complexity based on either medical decision making or total time spent with the patient.
- Example: If the visit includes in-depth medical evaluation, differential diagnosis, and management of diseases, a 99 code is likely appropriate.
92 Codes (Ophthalmological/Eye Codes)
- Codes range: 92002, 92004, 92012, 92014.
- Purpose: Used specifically for ophthalmological services, focused primarily on the examination and assessment of the visual system.
- Application: Employed mostly for routine or comprehensive eye exams involving evaluation and management of stable or non-complex eye conditions, vision checks, and initiation of diagnostic or treatment programs for new or established ocular conditions.
- Documentation: Requires documentation of history, general observation, examination of the eye and adnexa, and relevant diagnostic/treatment plans.
- Example: Annual routine eye exams or refraction for glasses commonly use 92 codes. These may also apply to intermediate or comprehensive exams that do not require extensive medical decision making.
Key Differences between 99 and 92 Codes
| Criteria | 99 Codes (E/M) | 92 Codes (Eye Codes) |
| Focus | Medical evaluation and management | Ophthalmological/visual evaluation |
| Typical Use | Medical/complex ocular conditions | Routine/annual eye exams, vision care |
| Documentation | Detailed medical history, decision making | Focused on eye structures, vision, and/or total time treatment for visual system |
| Examples | Diabetic retinopathy management, glaucoma post-surgical care | Routine vision check, refraction, presbyopia |
| Reimbursement | Can be higher for complex cases | Generally lower, annual frequency limitations |
| Coding Frequency | Based on complexity and/or time | Typically once/year for the same level of service |
99 Codes vs 92 Codes: When to Use Each Code Set
- Use 99 Codes if:
- The primary reason for the visit is a medical eye problem requiring clinical management, diagnosis of complex disease, or in-depth medical counseling.
- The examination includes substantial medical decision-making, differential diagnosis, systemic disease implications, or coordination of care.
- Time spent or the complexity of the condition is significant.
- Use 92 Codes if:
- The visit is for routine eye examination (often for glasses, contact lenses, or screening).
- The focus is on general evaluation or management of stable or simple eye conditions, without complex medical decision making.
- Insurance plans might restrict 92 codes to once per year per patient, so check your patient’s benefits.
Common Billing & Coding Considerations
- 92 Codes should not typically be used for the management of serious or chronic medical eye conditions; these situations demand the more medically complex 99 codes.
- For follow-ups or ongoing management of diagnosed medical eye conditions (such as after surgery, or for chronic diseases), the 99 code series is most appropriate.
- The use of improper codes (e.g., 92 codes for complex medical cases) can lead to claim denials or audit risks.
- Reimbursement rates can differ. Some services may be reimbursed more favorably under E/M codes (99) for medically complex care, while routine or comprehensive visual exams are often reimbursed under eye codes (92).
Practical Examples
- Example 1: A patient presents for an annual vision check and possible update of eyeglasses. Use a 92 code (e.g., 92014 for established patient comprehensive eye exam).
- Example 2: A patient presents with sudden vision loss, requiring diagnosis, differential, evaluation of systemic disease impact, and medical management. Use a 99 code (e.g., 99204 for new patient, moderate/high complexity).
- Example 3: Ongoing glaucoma management with adjustments to treatment plan—bill with a 99 code, reflecting ongoing medical management.
Additional Expert Insights
- Insurance limitations: Many insurance carriers restrict the frequency of 92 codes, permitting them only once per year, while 99 codes may be billed more based on medical necessity.
- Documentation requirement: Both code sets require comprehensive documentation, but the focus and criteria differ – ensure the selected code is substantiated by the clinical record.
- Revenue considerations: Selecting the most accurate code for the nature of the visit can substantively affect practice revenue and compliance.
Key Things to Remember
99 codes (E/M codes) are designated for medical evaluation and management of eye conditions and require more detailed decision-making or time-based documentation, while 92 codes (eye codes) are used primarily for routine or comprehensive examinations of the visual system. 99 codes vs 92 codes: It’s very important to use the proper application of each code set is not only critical for compliance but also has significant billing and reimbursement implications. Always align the selected code with the complexity, documentation, and primary purpose of the patient encounter. Contact ECBC for your Ophthalmology billing and coding.
