Besides being extremely challenging, ophthalmology is one of the medical specialties with the highest claim denial rates. According to a study published in Becker’s ASC Review, the claim denial rate for ophthalmology is 13%, while the average claim denial rate in the industry is 5-10%.
One of the main reasons for claim denials is coding errors. From consultation to routine visits and extensive eye exams to E/M visits, ophthalmologists have a hard time selecting the most appropriate code for their services.
Today, we will decode CPT code 92014 to help ophthalmologists master eye visit codes. Continue reading as we discuss its descriptor, real-world examples, applicable modifiers, and billing best practices.
CPT Code 92014 – Description
The Current Procedural Terminology (CPT) code 92014 appears in the ‘Established Patient General Ophthalmological Services and Procedures’ code range as maintained by the American Medical Association (AMA).
It is reported on the insurance claim form to indicate that an ophthalmologist performed a comprehensive medical eye exam of an established patient for the initiation or continuation of a diagnostic and treatment program. It may involve one or more visits for ongoing eye care.
Important Note: An established patient is one who has seen (face-to-face) the same healthcare provider or any other qualified provider from the same medical specialty within the past 36 months (3 years).
The in-person eye visit usually occurs in an office or outpatient setting. It involves a series of non-invasive eye tests like visual acuity, gross or confrontational visual fields, refraction, slit lamp, and glaucoma.
Medicare covers CPT code 92014. As per its Physician Fee Schedule, the current reimbursement rate for a comprehensive eye exam is between $109.76 and $157.08, depending on the MAC locality and facility. However, you must prove the medical necessity for this complete medical eye exam through an accurate diagnosis code and adequate documentation.
Scenarios Where CPT Code 92014 is Applicable
Now that you understand what services or procedures CPT code 92014 covers, let’s look at some real-world examples where this code can be applied.
A Patient with A Family History of Glaucoma Undergoes A Complete Eye Exam
Imagine that a 45-year-old man with a family history of glaucoma (a disease that damages the optic nerve) visits his ophthalmologist complaining of intense eye pain and blurred vision. His physician recommends a comprehensive eye exam to check if he, too, has glaucoma.
First, the ophthalmologist records the established patient’s medical history, including the general medical observation. Next, he performs a series of eye tests to evaluate and document 12 factors like ocular adnexa, extraocular motility, dilation, and intraocular pressure. The comprehensive examination ends with a diagnostic and treatment program, such as prescribing medicines and scheduling a follow-up visit.
Since the ophthalmologist covered all three components of a comprehensive eye visit, he will bill the outpatient encounter with his established patient with CPT code 92014 for rightful reimbursement.
A Patient with Diabetic Retinopathy Gets An Eye Exam for Ongoing Care
Now consider a diabetic woman in her 50s visiting her ophthalmologist. The same eye specialist had diagnosed the woman with diabetic retinopathy 2 years ago. Back then, the patient had complained of partial vision loss. After considering her medical history and running a few eye tests, the ophthalmologist detected damage to the retina caused by increased sugar in the blood vessels.
To manage her condition and prevent further complications like blindness, the ophthalmologist calls her for her annual eye exam. He documents her chief complaint – hazy vision – performs eye tests to evaluate 12 factors, and ends the visit with a revised treatment plan.
Since the woman is a Medi-Cal beneficiary, he will use CPT code 92014 for insurance claim filing and reimbursement collection.
An Aging Patient with Blurred Vision Undergoes A Complete Eye Exam for Macular Degeneration
For our last example, think of a patient who is almost 70 years of age and has a history of smoking. He visits his ophthalmologist complaining of central vision loss and difficulty recognizing familiar faces. His vitals reveal high blood pressure and hypertension. Considering the patient’s age, past lifestyle, and current vital signs, the ophthalmologist recommends a comprehensive-level eye test to confirm or rule out age-related macular degeneration (AMD).
The ophthalmologist records the patient’s medical history, conducts several eye tests to determine 12 factors like the conjunctiva, the retina and vessels, pupil dilation, and optic nerve discs, and prescribes low-vision eyeglasses to restore impaired vision.
He will bill the visit with CPT code 92014 to collect reimbursement from the patient’s primary insurance payer.
Applicable Modifiers for CPT Code 92014
CPT code 92014 can be reported on its own on the correct claim line. However, in certain circumstances, you must append the appropriate modifier to provide supplemental information to the insurance payer.
Modifiers can affect the final reimbursement rate. Moreover, missing or invalid modifiers are known to trigger claim denials. So, you must read this section carefully.
Modifier LT
Modifier LT is a location modifier. It explains to the insurance payer that the ophthalmologist performed a comprehensive eye examination and evaluation of the left eye.
Modifier RT
Likewise, modifier RT explains that the complete medical eye exam was only performed on the right eye.
Modifier 50
You must append modifier 50 if the comprehensive eye examination occurred bilaterally (on both eyes).
Modifier 25
You can use modifier 25 if a separate evaluation and management (E/M) service was performed on the same day as the comprehensive eye exam. It prevents claim duplication and helps the payer identify the two visits as distinct. Hence, separately reimbursable.
Modifier 57
Although modifier 57 is usually appended with an E/M service code, you can use it with CPT code 92014 to indicate that the complete eye exam led to the decision to perform eye surgery.
Modifier AI
Modifier AI is an HCPCS modifier and is mainly used for Medicare claims. It indicates that the principal physician who performed the comprehensive eye exam is different from other eye specialists involved in the patient’s ongoing eye care.
Some other medical modifiers that may be appended with CPT code 92014 include modifiers 22 (increased procedural services), 52 (reduce What is Modifier 52? | Description, Examples & Usage Guided or terminated services), and 59 (distinct procedural service).
CPT Code 92014 – Billing & Reimbursement Guidelines
Even the most seasoned physicians and medical billers make the mistake of thinking that every CPT code has the same billing rules and requirements for reimbursement. With this thought pattern, they are unable to tweak their billing workflow when needed. As a result, their incorrect billing practices trigger claim denials.
You must follow the code-specific billing best practices and reimbursement guidelines to mitigate claim denials. We have mentioned some below for CPT code 92014. Take a look!
Differentiate Between A Routine Visit and An Eye Exam
The first billing rule for CPT code 92014 is to discern whether the established patient visit was routine or a comprehensive medical exam. Ophthalmologists have a vast code set dedicated to their medical specialty. For outpatient visits alone, they have consultation, eye visits, and E/M codes, which makes the appropriate code selection extremely challenging.
However, they can differentiate between a routine visit and a comprehensive eye exam by considering the diagnosis and the clinical documentation. An eye exam is medically necessary for patients at high risk of severe vision problems (e.g., blindness). In contrast, a routine eye test is preventive and often not covered by insurance payers.
Report When All 3 Components Were Performed
You can only report CPT code 92014 when the ophthalmologist performs all three components of a comprehensive eye exam. These are as follows:
Patient History
- Chief complaint
- History (including family history)
- General medical observation
Examination
All the 12 elements of the eye exam must be performed and documented unless the patient’s health does not allow it. In this case, you must declare your reasons.
- Anterior chamber
- Conjunctiva
- Cornea
- Dilation (as medically necessary. If not dilated, document why)
- Extraocular motility
- Gross or confrontational visual fields
- Intraocular pressure
- Lens
- Ocular adnexa
- Optic nerve discs
- Pupil and iris
- Retina and vessels
- Visual acuity
Diagnosis and Treatment Program
- Prescribing medication, contact lenses, or glasses
- Scheduling consultations
- Scheduling follow-up appointments
- Arranging special ophthalmological diagnostic or treatment services
- Recommending laboratory procedures/ radiology services
- Recommending a major or minor surgery
- Advising a tailored care routine
You can use the appropriate modifiers (22 or 52) with CPT code 92014 if the services were reduced or expanded during the encounter, such as the ophthalmologist only checked for 9 out of 12 factors.
Pair with the Accurate Diagnosis Code
To prevent a claim denial, your chosen diagnosis code must support CPT code 92014’s usage. The diagnosis code must indicate the medical necessity of a complete eye exam. According to Medi-Cal, the appropriate ICD-10 diagnosis codes for reporting CPT 92014 are:
- H52.00 to H52.7
- H53.50 to H53.59
- H53.60 to H53.69
- Z01.01
Maintain and Submit Adequate Documentation
As mentioned before, documentation and diagnosis are the primary distinguishing features between routine eye visits and comprehensive exams. Therefore, you must support CPT code 92014’s usage with detailed documentation to justify its medical necessity.
You must document the patient’s medical history, current condition, the performed tests, their results, and the recommended treatment plan. You may also attach referral letters if you are referring the patient to another specialist or a general physician sent the patient to you.
Report Once A Year Unless the Payer Allows It
Most insurance payers, including Medicare and Medicaid, cover CPT code 92014 if the complete medical eye exam was medically necessary. However, its frequency is limited to once a year. They call it an “annual eye exam” to prevent, diagnose, or manage conditions like glaucoma, diabetic retinopathy, macular degeneration, and cataracts.
Therefore, you must report this code once in 12 months unless the patient’s insurance payer allows it. You can confirm the frequency of reporting CPT code 92014 by reading the provider-payer contract or communicating with the payer.
Do Not Report for Telemedicine or Inpatient Stays
CPT code 92014 is only applicable for in-person eye exams in outpatient or office settings. You cannot report this code if the comprehensive-level eye exam occurred during an inpatient stay or online through services like telemedicine. Failure to follow this billing rule will result in a claim denial.
Final Word
We tried our best to decode CPT code 92014 in this detailed guide. From discussing its descriptor to practical scenarios and applicable modifiers to billing guidelines, we gave you a lowdown on code 92014 and its appropriate usage for reimbursement collection.
However, if you are still confused or want to save some time and trouble, consider outsourcing medical billing to professionals at MediBillMD. Our full-stack ophthalmology billing services include CPT coding at the hands of AAPC-certified coders, helping you submit clean and compliant claims every time.
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