Ophthalmology and Optometry Coding Alert

When an ophthalmologist is summoned to the emergency department (ED) of the local hospital, its not unusual for the billing to be a little complicated. Here is a case study submitted by Valley Cataract Institute, based in Brownsville, TX.

A 45-year-old insulin-dependent diabetic, five days post-op vitrectomy for vitreous hemorrhage, traction proliferative retinopathy (surgery done in a town two hours away), appears in the local emergency room with eye pain, nausea and vomiting. The ED physician asks the local ophthalmologist to see the patient due to lack of transportation to operating surgeon. The patient was found to have a mild iritis and secondary glaucoma. She was treated for the iritis, secondary glaucoma, and nausea and vomiting. A metabolic work-up was done. Time spent was 1 hour. The patient is Medicare/Medicaid. How would you code this encounter?

There are two basic answers to this question:

1. A different provider. The fact that a different surgeon performed the surgery actually makes the coding simpler, says Raequell Duran, COA, president of Practice Solutions, of Santa Barbara, CA, and an ophthalmology coding expert. When a patient has a surgery that has a post-op period, and then sees another ophthalmologist, the claim system recognizes that the new doctor has a different identification number, says Duran. So the ED visit would not be part of the global package, and the ophthalmologist who went to the ED to care for the patient wouldnt need to use a modifier on the claim.

Note: Vitrectomies have a 90-day postoperative period.

This is true of surgery done during the post-op period, too, says Duran. Lets say a patient has cataract surgery and the retina detaches a week later. The patient goes to a second doctor outside of the cataract surgeons groupa community retina specialist this timeto repair the detachment. Later it redetaches. The retina specialist decides the patient needs to see a retina super-specialist at the local university, who operates on the re-detachment. Each of these doctors, says Duran, gets paid the full fee for the surgery, despite the fact that the last two operations took place during post-op periods. This is because they do not share a common provider number and, therefore, are not part of any global package.

2. New/established patient office/other outpatient visit. As far as coding the visit to the emergency room itself, the ophthalmologist who was not the operating surgeon use a new patient office or other outpatient E/M level of care code (99201-99205), says Duran. The ED services codes (99281-99285) wont work because the patient has already had an ED encounter by the ED physician which will be coded as such.

Payers consider that when a specialist is called into the ED the specialists services are either a consultation or a transfer of the specific care which would be a new patient (99201-99205) or established patient (99211-99215) office or other outpatient visit. The encounter would not be a consultation code. I wouldnt call it a consult for Medicare billing, because in the Medicare program, when the intention of the referring physician is for the consultant to evaluate and treat, a consult cannot be billed, says Duran. It is considered a transfer of care, she explains. This is clearly a case of the ED doctor wanting someone to treat
the patient.

You need to review the medical notes carefully to decide what level code to use, Duran says. It would probably be a level three, or possibly a level four. But this depends entirely on the documentation. If the glaucoma had been acute angle closure glaucoma, instead of secondary, then the level of risk would have been higher, Duran notes. But mild iritis and secondary glaucoma probably do not warrant the highest code in the range.