Hi Thomas,
I did a little research and here is an article I found that discuss your question.
I also would like to add the importance of following each Payers' guidelines for every scenario.
Hope this help.
E/M vs. Eye Codes: Which Should You Use?
RIVA LEE ASBELL, Fort Lauderdale, Fla.
One of the most difficult choices for most ophthalmic practitioners is deciding which set of codes to use — the Evaluation and Management (E/M) codes or the Ophthalmology (Eye) Codes. The ophthalmic practices are the only specialties with the privilege of choosing from two sets of codes for coding office encounters. This series, which will run in three parts, will help you, the optometrist make the correct choice.
Here, in Part I, I present an overview of the E/M requirements. Part II will provide an overview of the Eye Codes, and Part III will offer an algorithm guide for making "The Choice."
Background of E/M and eye codes
Many practitioners prefer using the Eye Codes, believing they are easier to use and more audit-proof. This is not necessarily so. If you use only eye codes, not only are you punishing yourself financially, but you also may be found to be upcoding or down-coding under audit. For example, the intermediate eye code for established patients (CPT code 92012) isn't always suitable for coding frequent follow-up visits, such as a follow-up examination for a corneal abrasion. (The correct code for healing a corneal abrasion is often E/M code 99212).
The objective, and what Centers for Medicare and Medicaid Services (CMS) wants, is for you to code correctly — to neither upcode nor downcode.
With the increase in CERT (Comprehensive Error Rate Testing) audits and the advent of the RAC (Recover Audit Contractor) audits, proper selection and correct and complete chart documentation takes precedence over everything else.
E/M codes
CMS first established the new E/M codes in 1994-1995 with the examination requirements for single organ systems (such as eyes) presented in 1997. The original document, "Documentation Guidelines for Evaluation and Management Services" jointly issued by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA) (now CMS) may be found at:
www.cms.hhs.gov/medlearn/emdoc.asp.
It was, and remains, difficult to learn the first time, but it has its advantages in that it's very black and white compared with the eye codes, which contain gray areas. It's very beneficial to master them. If used properly with a forced entry form for chart documentation, E/M codes become easy to master. (More on the chart examination form later.)
E/M codes are defined by seven components. The first three are used in conjunction with each other to determine the code for outpatient office visits/consultations. They elevate in levels of severity from one to five, with five being the highest, or most severe. These components are: History, Examination and Medical Decision Making. Some important points for each follow.
