Procedural Coding

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Decision making can be broken down into what three areas?

1. # of diagnoses or management options considered 2. Amount/complexity of diagnostic tests, other info 3. overall risk

History can be broken down into what three areas?

1. HPI 2. ROS 3. PFSH

99XXX can be broken down into what three areas?

History Examination Decision making

Describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy.

Intermediate Ophthalmological Services

Established patient

One who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years

92012

Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, ESTABLISHED patient

92002

Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, NEW patient

92015

Refraction

Describes services in which a special evaluation of part of the visual system is made, which goes beyond the services included under general ophthalmological services, or in which special treatment is given

Special Ophthalmological Services

Adjunctive Ophthalmology Codes can be broken up how?

Technical component Professional component Both

368.40

VF defect

What do CPT codes do?

used to report the work that you perform during a basic exam

Special Ophthalmological Services (what are the numbers?)

92XXX

Three subsets of CPT codes

Adjunctive Ophthalmology Codes Evaluation and Management Codes S-codes

CPT is owned and administered by whom?

American Medical Association (AMA)

365.01

Glaucoma suspect

A general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthamoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs; i.e. prescription medication, arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.

Comprehensive Ophthalmological Services

92014

Comprehensive, established patient, one or more visits

92004

Comprehensive, new patient, one or more visits

CPT (what does it stand for)

Current Procedural Terminology

What are E/M codes used for?

Describe any medical exam, including eye exams

92070

Fitting of contact lens for treatment of disease

92083

Full threshold visual field

367.20

astigmatism

918.1

corneal abrasion

What are Adjunctive Ophthalmology Codes used for?

describe eye exams ancillary services beyond a basic eye exam

365.11

glaucoma

92018

gonioscopy

367.1

myopia

New patient

one who has not received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years

367.4

presbyopia


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