Lesson Summary

This lesson reviews five real-world optometric cases to illustrate how to apply Evaluation and Management (E/M) coding (99- codes) and ophthalmologic codes (92- codes) when billing to medical insurance. The cases emphasize decision-making based on Problem, Data, and Risk (PDR)—with a focus on Problem and Risk since Data is often minimal.

Here is a breakdown of the cases:

• Simple Cases:
  • Case 1: Cataracts
  • Case 2: Subconjunctival Hemorrhage
  • Case 3: Allergic Conjunctivitis
  • Case 4: Preseptal Cellulitis
  • Case 5: Corneal Abrasion

Takeaways:

• Prescription drug management raises the risk level—important for justifying higher level E/M codes.
• If time spent is short (equating to a low level 99- exam if coding based on TIME), using MDM often results in better reimbursement.
• Compare 99- vs 92- codes—sometimes 92004/92012 pays more than 99- codes.
• Document thoroughly to support your coding choice, especially around risk and complexity.