{"id":8699,"date":"2019-05-14T13:32:52","date_gmt":"2019-05-14T08:02:52","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=8699"},"modified":"2024-10-17T12:11:31","modified_gmt":"2024-10-17T12:11:31","slug":"optometry-service-basics-medical-billers-and-coders","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/optometry-service-basics-medical-billers-and-coders\/","title":{"rendered":"Understand Basics of Optometry E\/M Coding"},"content":{"rendered":"

Typically, eye care practitioners don’t use the E\/M codes for what most Optometry service<\/a> considers a general eye examination. They are more typically used for patient encounters where the patient presents with a medical complaint or a continuation of medical case management (i.e., glaucoma, allergy, dry eye). The five levels of E\/M codes are universally applicable for all manner of disease, yet they are more complicated to apply and require more than one page of chart documentation for a comprehensive examination.<\/p>\n

Optometry E\/M coding:<\/h2>\n

So, what\u2019s E\/M Coding? The acronym \u2018E\/M\u2019 stands for \u2018evaluation and management. An E\/M code consists of five digits. The leading four digits are \u20189920\u2019 for new patients and \u20189921\u2019 for established patients. The fifth digit of the E\/M code can range from level \u20181\u2019 to level \u20185\u2019, which directly translates to the level of reimbursement from the insurance. This means the higher the level, the higher the reimbursement.<\/p>\n

Generally, E\/M coding uses three components:<\/h2>\n

History, medical decision-making (MDM), and exam. There is also an option to code based on time spent with the patient; however, the time option is less popular and more difficult to track. \u00a0For each of the components, the doctor is required to perform and document certain data during the patient encounter. Generally, the more, and the more complex, data is documented, the higher the resulting E\/M level.<\/p>\n

History:<\/h3>\n

In the E\/M world, history consists of four areas: Chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past family, medical and social history (PFSH) (including medications and allergies). Depending on how much data you document in each of these areas, you end up with a \u2018problem-focused, \u2018expanded problem-focused, \u2018detailed\u2019 or \u2018comprehensive\u2019 history for the patient.<\/p>\n

MDM:<\/h3>\n

MDM consists of three areas: Problem points, risk level, and data points. In order to achieve any E\/M level, two out of these three areas must be documented. The overall MDM complexity varies from \u201cstraightforward\u201d to \u201clow\u201d, \u201cmoderate\u201d, and \u201chigh\u201d, depending on the number of problem points, data points, and risk level. The higher the MDM complexity, the higher the E\/M level you can achieve for any given encounter.<\/p>\n\n\n\n\n\n\n\n
MDM Complexity<\/strong><\/td>\nProblem Points<\/strong><\/td>\nRisk Level<\/strong><\/td>\nData Points<\/strong><\/td>\n<\/tr>\n
Straightforward<\/td>\n1<\/td>\nMinimal<\/td>\n1<\/td>\n<\/tr>\n
Low<\/td>\n2<\/td>\nLow<\/td>\n2<\/td>\n<\/tr>\n
Moderate<\/td>\n3<\/td>\nModerate<\/td>\n3<\/td>\n<\/tr>\n
High<\/td>\n4<\/td>\nHigh<\/td>\n4<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Problem points:<\/strong>
\nThey are assigned based on the nature of your encounter diagnoses. Their ratings include \u201cself-limited or minor\u201d (1 point), \u201cstable or improving\u201d (1 point), \u201cworsening\u201d (2 points), \u201cnew dx with no additional workup planned\u201d (3 points), and \u201cnew dx with additional workup planned\u201d (4 points). The more data points, the higher the resulting E\/M level. To get to a good number of problem points, document ratings for at least 2 diagnoses, including the primary diagnosis.<\/p>\n

Risk levels:<\/strong>
\nThey include \u201cNone\u201d, \u201cMinimal\u201d, \u201cLow\u201d, \u201cModerate\u201d and \u201cHigh\u201d, where \u201cHigh\u201d would only be appropriate in complex circumstances where the patient\u2019s life is in jeopardy.<\/p>\n

Data points:<\/strong>
\nThese are assigned based on certain tasks or decisions that doctors make to properly treat the patient\u2019s condition(s). For example, the doctor can review or order the patient\u2019s clinical lab results (1 point), review and summarize old patient records (2 points), obtain the patient\u2019s old records (1 point), and\/or discuss certain tests with the performing physician (1 point). You can document problem points and risk levels instead. Again, only two out of the three MDM areas need to be met in order to qualify for an E\/M code.<\/p>\n

Exam:<\/h3>\n

You will find a \u201cgeneral\u201d E\/M process to assess the exam component, which is based on the procedures and documentation needs of a general physician<\/a>. However, since providers from different healthcare specialties, such as eye care, vary greatly in their ways to conduct an exam, CMS came up with E\/M coding requirements for specialty exams. For eye care, you need to consider fourteen exam elements in determining the correct E\/M level: Neurologic, Psychiatric, Aided or unaided visual acuity, Motility (EOM), Intraocular pressure, Confrontation visual field, Adnexa (lids\/lashes, lacrimal, orbit, and p. lymph nodes), Bulbar and palpebral conjunctiva, Cornea, Anterior chamber, Iris\/pupil, Lens, Dilated evaluation of disc\/optic nerve, Dilated evaluation of posterior segment (vitreous, macula, vessels and periphery)<\/p>\n

Based on how many of those fourteen exam elements you performed and documented, your exam will be rated as \u201cproblem-focused\u201d, \u201cexpanded problem-focused\u201d, \u201cdetailed\u201d or \u201ccomprehensive\u201d.<\/p>\n\n\n\n\n\n\n\n
Exam Elements<\/strong><\/td>\nExam Rating<\/strong><\/td>\n<\/tr>\n
1-5<\/td>\nProblem Focused<\/td>\n<\/tr>\n
6-8<\/td>\nExpanded Problem Focused<\/td>\n<\/tr>\n
9+<\/td>\nDetailed<\/td>\n<\/tr>\n
14<\/td>\nComprehensive<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

After documenting history, exam elements, and MDM per the above guidelines, you can determine the appropriate E\/M code. As mentioned above, the E\/M level you can achieve depends on your documentation and on whether the patient is new or established. Below are two tables that summarize the required documentation for history, exam, and MDM for (1) new patients and (2) established patients.<\/p>\n

New Patients<\/h3>\n\n\n\n\n\n\n\n\n
Level<\/strong><\/td>\nE\/M Code<\/strong><\/td>\nHistory<\/strong><\/td>\nExam<\/strong><\/td>\nMDM<\/strong><\/td>\n<\/tr>\n
1<\/td>\n99201<\/td>\nProblem-focused<\/td>\nProblem-focused<\/td>\nStraightforward<\/td>\n<\/tr>\n
2<\/td>\n99202<\/td>\nExpanded problem-focused<\/td>\nExpanded problem-focused<\/td>\nStraightforward<\/td>\n<\/tr>\n
3<\/td>\n99203<\/td>\nDetailed<\/td>\nDetailed<\/td>\nLow<\/td>\n<\/tr>\n
4<\/td>\n99204<\/td>\nComprehensive<\/td>\nComprehensive<\/td>\nModerate<\/td>\n<\/tr>\n
5<\/td>\n99205<\/td>\nComprehensive<\/td>\nComprehensive<\/td>\n\n

High<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Established Patients<\/h3>\n\n\n\n\n\n\n\n\n
Level<\/strong><\/td>\nE\/M Code<\/strong><\/td>\nHistory<\/strong><\/td>\nExam<\/strong><\/td>\nMDM<\/strong><\/td>\n<\/tr>\n
1<\/td>\n99211<\/td>\nNone<\/td>\nNone<\/td>\nNone<\/td>\n<\/tr>\n
2<\/td>\n99212<\/td>\nProblem-focused<\/td>\nProblem-focused<\/td>\nStraightforward<\/td>\n<\/tr>\n
3<\/td>\n99213<\/td>\nExpanded problem-focused<\/td>\nExpanded problem-focused<\/td>\nLow<\/td>\n<\/tr>\n
4<\/td>\n99214<\/td>\nDetailed<\/td>\nDetailed<\/td>\nModerate<\/td>\n<\/tr>\n
5<\/td>\n99215<\/td>\nComprehensive<\/td>\nComprehensive<\/td>\nHigh<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

You might have realized that the E\/M coding<\/a> process can be quite time-consuming and prone to errors. Consequently, a lot of providers tend to under-code or over-code their exams, leaving money on the table or risking insurance audits. So, why not utilize one of the best billing<\/a> and coding expert available. MBC<\/a> is doing billing and coding for more than 8 years, to know more about our services contact us at 888-357-3226<\/a><\/strong>\/ info@medicalbillersandcoders.com<\/a><\/p>\n

FAQs:<\/h2>\n

1. What does E\/M coding stand for, and why is it important?<\/h3>\n

E\/M stands for “evaluation and management.” It’s crucial for determining reimbursement levels based on the complexity of patient encounters and the services provided.<\/p>\n

2. How are E\/M codes structured?<\/h3>\n

E\/M codes consist of five digits, starting with “9920” for new patients and “9921” for established ones, with the last digit indicating the service level.<\/p>\n

3. What are the main components of E\/M coding?<\/h3>\n

E\/M coding involves three components: history, medical decision-making (MDM), and examination. Proper documentation in these areas impacts the coding level and reimbursement.<\/p>\n

4. How do I determine the appropriate E\/M level for a patient?<\/h3>\n

The E\/M level is based on the complexity of the history, the details of the exam performed, and the MDM documented during the patient encounter.<\/p>\n

5. Why should I consider outsourcing my E\/M coding?<\/h3>\n

Outsourcing to experts can minimize errors in coding, maximize reimbursements, and save time, allowing you to focus on patient care rather than billing complexities.<\/p>\n","protected":false},"excerpt":{"rendered":"

Typically, eye care practitioners don’t use the E\/M codes for what most Optometry service considers a general eye examination. They are more typically used for patient encounters where the patient presents with a medical complaint or a continuation of medical case management (i.e., glaucoma, allergy, dry eye). The five levels of E\/M codes are universally […]<\/p>\n","protected":false},"author":2,"featured_media":8700,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[469],"tags":[759,813,920,1592,1593,144,816,58,27],"class_list":["post-8699","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-optometry-billing-services","tag-optometry-billing-2","tag-optometry-billing-companies","tag-optometry-coding","tag-optometry-coding-service","tag-optometry-ehr","tag-outsource-medical-billing","tag-outsourced-medical-billing-services","tag-rcm","tag-revenue-cycle-management-2"],"yoast_head":"\r\nOptometry Service Basics: Medical Billers and Coders<\/title>\r\n<meta name=\"description\" content=\"MBC is doing optometry billing and coding for more than 8 years, to know more about our services contact us at 888-357-3226\" \/>\r\n<meta name=\"robots\" content=\"index, follow, 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