Basics of Sensorimotor Exam
Primary eye care practices often encounter issues relating to the neurological system. One of the first signs of a serious neurological issue may, in fact, be extraocular muscle (EOM) abnormalities that manifest during diagnostic testing. The sensorimotor examination is a critical diagnostic test in some instances when you suspect a neurological issue. A basic sensorimotor exam evaluates ocular range of motion to determine if the eyes move together in the various cardinal positions of gaze (12:00, 3:00, 9:00, etc.). This exam element is commonly noted as ocular motility, or extraocular muscles (EOM), in the chart note. A normal range of motion is often noted as ‘full’ or ‘within normal limits.’ For accurate insurance reimbursements, let’s understand CPT 92060 coding guidelines in detail.
CPT 92060 Coding Guidelines
- CPT 92060 description: Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure). CPT code 92060 is frequently billed by pediatric, neuro-ophthalmology, and comprehensive ophthalmology practices for the sensorimotor exam.
- CPT lists basic sensorimotor exam as a required exam element of a comprehensive eye exam (920×4); it is an incidental component and not separately reimbursed. A quantitative sensorimotor examination, utilizing prisms to measure ocular deviation, is a more extensive exam and may be separately billable.
- Unlike a basic sensorimotor exam, CPT describes the diagnostic test 92060, as sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure). Fundamentally, this test requires the clinician to assess both eyes (and is therefore bilateral); it should not be billed per eye. Pertinent diagnoses include but are not limited to: diplopia, exotropia, esotropia, hypertropia and paralytic strabismus.
- The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) issued a position statement in 1999. They state, ‘Sensorimotor eye exam includes measurement of ocular alignment in more than one field of gaze at distance and/or near, and inclusion of at least one appropriate sensory test in patients who are able to respond.’ Measuring only primary gaze at distance would not satisfy the requirements. You should include ocular alignment measurements in more than one field of gaze. Primary gaze at distance and near for accommodative esotropia would satisfy the criteria.
- Examples of sensory function testing include Worth 4 dot, Maddox rod, and Bagolini lenses. The assessment of sensory function is complementary to the evaluation of the motor function as the term ‘sensorimotor’ implies. It is no less important and is an essential part of the service.
- An order for the test should be noted in the chart. Test results for motor function are typically documented in a ‘tic-tac-toe’ format to represent different fields of gaze. Results of the sensory function test are noted, too. Examiners should note which stereopsis test is used and the scored findings (not just pass or fail). Results of a Worth 4 dot often note which lights were seen. An interpretation of the test results and the effect on the patient’s condition and course of treatment satisfy the interpretation requirements. Take care that the notations for the test are clearly identifiable and distinct from the office visit notes (e.g., stamp, boxed entry, separate page, etc.).
- Repeated testing is indicated when medically necessary for new symptoms, disease progression, new findings, unreliable prior results or a change in the treatment plan. In general, additional testing is warranted when the information garnered from the eye examination is insufficient to adequately assess the patient’s disease. For example, if a patient has a history of accommodative esotropia and the basic sensorimotor exam reveals an unstable or worsening condition, the more extensive test is justified. Insurance carriers would not expect a claim for a stable patient who presents with no complaints or one with a controlled condition.
Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various medical billing specialties. We referred American Optometric Association’s document to discuss sensorimotor exam CPT 92060 coding guidelines. If you are seeking assistance in billing and coding for your optometry practice, contact us at info@medisysdata.com / 888-720-8884
Reference: Vision Therapy and Neuro-Rehabilitation Optometric Considerations in Third Party Reimbursement
