Ophthalmology and Optometry Coding Alert

If you're not keeping track of your code utilization, you should, because CMS certainly is.

The agency keeps track of how often ophthalmologists report certain E/M codes -- and if you vary too much from the pattern established by physicians within the same specialty designation, CMS may want to know why.

Medicare recently released its utilization statistics for Part B services that it paid in 2006, with information provided for each specialty. Here's how ophthalmologists used the office visit E/M codes in calendar year 2006:

Source: "Medicare Part B Physician/Supplier National Data, Calendar Year 2006, Evaluation and Management Codes by Specialty."

In all, Medicare paid ophthalmologists for 6,107,074 office visits (99201-99215) in 2006. Nationally, 99204 and 99213 were the codes all specialties billed most frequently for new patient and established patient visits respectively.

Look at the allowed services for each office visit code as a percentage of the total, and compare them with your own practice's data:

Although the rates might vary in different locations, this data would lead Medicare to expect about 5 percent of your E/M visits to be 99204 and 46 percent to be 99213, for example.

If your own billing statistics are much different from this bell curve, you may want to review your physician's documentation and supporting medical necessity with the level of code assignment to make sure there are no documentation deficiencies or undercoding.

Remember: To report 99214, you must document at least two of the following: a detailed history, a detailed exam, and medical decision-making (MDM) of moderate complexity. You also need to be sure that the nature of the presenting problem and medical necessity support coding a level four. Many coding consultants recommend not selecting an established patient E/M code level above that supported by the MDM level.

Pitfall: Some insurers raise red flags when a practice only reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that level.

Bottom line: Choose the E/M code based on the documentation and medical necessity every time, and your coding will naturally reflect the ophthalmologist's range of services.

Do this: Download national billing statistics from http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp.