Ophthalmology and Optometry Coding Alert

Many practices have ophthalmologists and optometrists on staff, and sometimes there is confusion about how to coordinate billing when two providers see the same patient. Melodie Aeder, network manager for Andersen Eye Associates, a 10-ophthalmologist, 9-optometrist practice in Saginaw, MI, writes with a question about Medicare billing.

When one of the optometrists in a satellite office examines a patient and bills Medicare (99213), and then refers that patient to an ophthalmologist in a different office for a cataract evaluation, can the ophthalmologist bill Medicare for a comprehensive level of service? We have been told by one consultant, the ophthalmologist cannot bill anything above a level one service. Other consultants have disagreed and said a level four could be billed, as medically necessary.

First of all, in Medicare, optometrists are a different specialty designation from ophthalmologists. A separate visit to an optometrist in which a cataract is identified is paid separately, because an ophthalmologist needs to make the decision for surgery.

However, there is one big exception for Medicare. If the operation is being done the same day (or the next day) as the office visit (whether done by the optometrist or ophthalmologist) it cant be billed separately.

Medicare defines an office visit the day of or before surgery as a preoperative visit and is included in the global surgery package.

If surgery is not done the next day or the same day, then both the optometrist and the ophthalmologist may submit a bill for their services.

We talked to two coders, both of whom do cataract surgeries within the one day of the evaluation. If the optometrist sees a cataract when hes examining a patient, he does the cataract evaluation himself, says Carrie MacMillan, billing manager for Eye Specialists of Indiana, a four-optometrist, one-ophthalmologist practice in Indianapolis, IN. Medicare wouldnt pay for an office visit with an ophthalmologist as well, she says, acknowledging that this would be considered a preoperative visit for the cataract surgery. We wouldnt charge for a second office visit, and Medicare wouldnt pay for it, she stresses. As to whether the optometrist would bill an E/M services code (99202-99205, 99211-99215) or an ophthalmological services code (92002, 92004, 92012, 92014), that would depend on the other services that were done in addition to the cataract evaluation.

Pat Steingass, insurance coordinator for Spectrum Eye Care, a three-ophthalmologist, two-optometrist, one-optician practice in Findlay, OH, has chosen to code this way: the ophthalmologist would not bill at all until the patient came in to be measured for the intraocular lens before the surgery. This visit would be coded 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation).