Are documentation requirements consistent state-by-state for eye codes and E/M codes?
No. There is no national policy applicable to the eye codes. Many Medicare carriers do not publish local coverage policies for these services. Others publish detailed policies. In the absence of a policy, defer to the definitions in the CPT book for the eye codes. If your carrier publishes a policy, be sure to review it as it may contain additional documentation requirements not cited in the CPT book definition. For example, the use of mydriasis for the fundus exam is optional in the CPT description, but some Medicare carriers (e.g., TrailBlazers Health) require the use of mydriasis for the fundus exam to satisfy a comprehensive eye exam. Providers may hesitate to use the E/M codes because the system is complex. Satisfying the higher-level codes requires a great amount of documentation that may not fit on one piece of paper. The history-taking requirements are very specific and, if not complete, can down-code a new patient encounter by two levels of service. The decision-making compone
