Ophthalmology and Optometry Coding Alert

Follow 3 tips to keep your coding correct.

Approximately 10 percent of patients 66 to 74 years of age will have findings of macular degeneration. The prevalence increases to 30 percent in patients 75 to 85 years of age. With an aging population, are you getting the best reimbursement for all AMD's related services? Watch these three areas to ensure you file correctly for this growing area of ophthalmology care.

1. Combine Services for Diagnosis

When your ophthalmologist suspects AMD, he'll complete several tests to confirm the diagnosis. Some are as simple as a dilated eye exam, visual acuity test, or fundoscopy. He might also complete a fluorescein angiography if he suspects a patient might have wet AMD. These can all be done on the same day, but it would be unlikely due to the amount of time that a fluorescein angiography takes to perform.

Performing all the diagnostic tests on the same day, however, doesn't mean they're separately billable. Visual acuity and fundoscopy are part of the eye exam or E/M, not separately billable, say experts. Fluorescein angiography is separately billable per eye when pathology is present.

If your ophthalmologist completes fluorescein angiography, you have three coding options depending on the type of test and imaging:

• 92230 -- Fluorescein angioscopy with interpretation and report
• 92235 -- Fluorescein angiography (includes multiframe imaging) with interpretation and report
• 92240 -- Indocyanine-green angiography (includes multiframe imaging) with interpretation and report.

You'll submit a diagnosis based on whether your physician confirms dry or wet AMD. Report 362.51 (Nonexudative senile macular degeneration) for dry AMD or 362.52 (Exudative senile macular degeneration) for wet AMD.

Other possibilities: ICD-9 includes two more diagnosis choices for AMD, though you won't rely on them as often. 362.50 (Macular degeneration [senile], unspecified) isn't normally used because the physician can tell what type it is by the examination performed. You'll use 362.53 (Cystoid macular degeneration) if there is swelling and a cyst located in the macula.

2. Know Globals for Your Treatments

Treatment plans for AMD run the gamut from "widely accepted" to "rarely considered reimbursable."

Watch your days: Many AMD treatments carry a 90-day global period (such as 67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation). Most also state that the code covers "one or more sessions," so you can only report the initial treatment for the eye.

When there are multiple sessions on the same eye during the global period, only the initial treatment is covered. If more treatments are needed within the 90-day global, you can only bill the medication -- not the procedure.

A few procedures don't have a 90-day global period, however, so remember to charge follow-up treatments when applicable. For example, injections of drugs such as Lucentis, Macugen, and Avastin 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) and photodynamic therapy 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) have a 0-day global.

3. Choose Your Visit Code Carefully

Ophthalmologists have the choice of using either eye codes (92002-92014) or outpatient E/M codes (99201-99215) for their examinations.

Some Medicare payers have local coverage determination policies on the eye codes, with specific guidelines as to what needs to take place to use the eye codes. Other Medicare payers do not have such policies. When that is the case, physicians should use the descriptor in CPT® as a guideline for what needs to take place to qualify for an intermediate or comprehensive eye exam.

"Some states also have guidelines regarding the services that must be rendered and documented for a comprehensive eye exam," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y. "Be sure to check to determine if your state has guidelines for ophthalmology office services."

These groups of codes will be your standbys, but a visit might sometimes merit one of the counseling codes 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) or 99402 (... approximately 30 minutes). Also remember that the 99401 and 99402 codes are for preventive counseling when the patient has no symptoms but may be at risk for problems for whatever reasons, says Mac.

These codes (99401-99404) are noncovered services by CMS and many private payers. If counseling dominates more than 50 percent of the face-to-face physician-patient encounter, physicians should report the appropriate E/M code based on the total time for the encounter. Documentation must include a detailed summary of the counseling, total time of the encounter and the amount of time spent for counseling. Again, keep in mind that the amount spent in counseling must be greater than 50 percent of the total time.