In any medical checkup, an examination of the eyes is commonplace. If you're getting new glasses or contacts, it's the whole reason you're there in the first place! As most Healthcare Investigators and Auditors are aware, visual screenings are usually part of the eye exam components of problem focused (CPT 99201-99215), preventive medicine (99381-99397), and Ophthalmological (92002- 92014) Evaluation and Management services. However, many are not aware that there are additional visual screening tests in the Medicine section of the CPT manual [1]:
99172: Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination[s] for contrast sensitivity, vision under glare)
99173: Screening test of visual acuity, quantitative, bilateral
99174: Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral
When reviewing your data, it may become a concern when there is a frequent pattern of these codes billed with an E&M. Especially noted in pediatric medicine providers, visual screening services are often seen in conjunction with the periodic preventive medicine visit, a problem focused visit, and occasionally both. While on an individual basis, payments for these claims may not seem that significant; however, when looking at inappropriate payments over time and at multi-provider practices, the financial risk can be high.
When is a vision screening separate from an eye exam reported as part of an E&M? As per the CPT manual [2], 99172 may not be used in addition to general ophthalmological services, E&M services, and 99173. It also indicates that CPT 99174 should not be reported in conjunction with the ophthalmology E&Ms, 99172, and 99173. For the most part, claim system edits should prevent payment of claims with these conditions; however, even unpaid claims may identify providers with a misunderstanding of billing for visual screenings.
As for CPT 99173, careful attention should be paid when there is a pattern of this code paid with an E&M code. The CPT manual specifies that this code may be billed with other identifiable unrelated services performed at the same time. However, it further specifies that "when acuity is measured as part of a general ophthalmological service or of an E&M service, it is a diagnostic examination and not a screening test."[3]
What Should I look for?
To identify at-risk practices, use an ad-hoc querying tool like QueryShield™ or your FWA analytics software such as PostShield™ to:
1) Find your top billers of 99173 and create patterns to see who routinely bills it with E&M or preventive medicine services.
2) Conduct medical record reviews of your significant outliers to ensure that the service, as per the CPT, "employs graduated visual acuity stimuli that allow for a qualitative estimate of visual acuity" and does not constitute a diagnostic service that would be included in the E&M service.
3) Review claims to see who is billing 99174 for the same member, same date of service as 99172 and/or 99173. Also, review claims to see if providers are staggering these different services across multiple consecutive dates of service to bypass any edits.
