Medical billing can be difficult to navigate, leaving you with a ton of questions – What can I bill? What can’t I? What is the right code? How much can I charge? Zyloware is here to break it all down for you!


The Basics:


Each state has its own requirements. To make sure you are following the correct requirements, you can find that information here. Minimum tests may be required but may not be a billable procedure according to CPT guidelines. Some minimum tests are color vision, stereopsis, cover test/procedure testing, keratometry, etc.


Refraction is always reported separately. It has been reported separately since 1992 and it always reported in addition to eye code or E/M code used.


If it has been over three years after seeing a patient, they are considered a new patient and should be billed as such. If it is within three years since the patient’s last visit then they are considered an establish patient and should be billed accordingly.


There are a total of 16 different E/M and eye codes to choose from. Eye codes are for comprehensive exams and intermediate exams, E/M codes are based upon Levels, which there are five of. There are also S-codes, which there is only one of. Each code has two parts, one for a new patient and one for an established patient. Eye codes are separate from E/M codes, meaning they do not go hand in hand, they are either other. The same rule applies for S-codes.


Eye Codes:


There are two different types of exams under eye codes: comprehensive and intermediate. The different between comprehensive and intermediate is for a comprehensive exam is an evaluation of the complete visual system and it always includes the initiation of a diagnostic treatment program. So, if the eye exam is limited to just a few sections of the eye, then it would be considered an intermediate exam.


When performing a comprehensive exam, like a yearly diabetic exam, dilation is not required, but posterior pole views are. Comprehensive exams do not have to be completed in one sitting. A patient can return a different day to complete the exam, but only the first day is billable. Any returning days cannot be billed.


When billing, make sure to always include initiation of diagnostic and treatment programs, which would include glasses count, radiological lab work, diagnostic testing, consultation, etc. If you need to perform a refraction exam, that must be reported separately from the other exams. The E/M code for comprehensive exam is 92004 for new patients and 92014 for established patients.


Intermediate exams are evaluations of new or existing conditions complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. These types of exams may or may not include dilation. Intermediate exams are mainly used for ER patients. Certain types of intermediate exams are subconj heme in HTN patients, K ulcer in CL wearer, etc. The E/M code for intermediate exam is 92002 for new patients and 92012 for established patients.


E/M Codes:


There are 5 levels to E/M codes. Typically, Levels 1 and 5 are not used; Level 1 is for technicians and/or nurses, while Level 5 is automatic audit, do NOT use unless you have a thorough understanding of criteria required. Level 2, 3, and 4 are used the most frequently, while Level 3 is used the most code. The higher the level (Level 5 being the highest and Level 1 the lowest), the more complex the visit. When selecting which is the appropriate E/M examination/level to choose, consider their history, the examination, and the medical decision made. The more complex, the higher the level to choose.


Based on if they are a new or established patient, also determines what level to examine and then bill. There are no guidelines for new patients when it comes to examinations, that is why you need to know that a new patient at a certain level is an established patient at the next level.


The E/M Codes for each Level and patient status are as follows:

New                                         Established

Level 2              99202                                      99212

Level 3              99203                                      99213

Level 4              99204                                      99214




S-codes are for routine ophthalmological exam with refraction. For new patients, you would use the code S0620 and for established patients, you would use S0621. These codes benefit the patient, allowing a doctor to appropriately discount services to patients who are cash paying or have no insurance coverage for routine exams.


Examining the Patient:


When examining the patient, it is important to follow the necessary steps and procedures to successfully diagnosis the issue. There are certain questions you must ask your patient before you start the examination. You must find out the chief complaint (CC); the chief complaint is the reason for the visit or why the patient is coming in to see you today. The chief complaint and the number one diagnosis must match, meaning the diagnosis must alleviate the chief complaint.


Order of questions to ask the patient when diagnosing the chief complaint:

  1. History of Present Illnesses (HPI)

Example: How often do you experience eye pain?

  1. Review of Systems (ROS)

Example: Are there issues with your ears, nose, or throat? Do you have any allergies?

  1. Past, Family, Social, and History (PFSH)

Example: What past procedures have you had? Is there glaucoma in your family history? Do you smoke cigarettes?


For each examination or level, there are different exam components to go over.

Components to a Comprehensive Exam are:


Components to an Intermediate Exam are:


Components to an Established Level 2 Exam:


Components to an Established Level 3 Exam:


Components to an Established Level 4 Exam:


Depending on the chief complaint and going over questions to ask patients, you can successfully determine with examination/ level to choose and bill accordingly**.


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** We are not coding/billing consultants and when I doubt refer to CPT guidelines to define exam components. This is strictly about minimum coding for insurance companies.


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