Ophthalmology and Optometry Coding Alert

If you don't know the difference between coding traumatic injuries treated in the office and in the emergency room, you could receive a blow to your reimbursement-ego the next time your ophthalmologist treats a firecracker burn.

Coding traumatic eye injuries depends on two factors: where the treatment was rendered and when the treatment was rendered.

Ophthalmologists provide traumatic eye injury treatment in two primary locations the office and the emergency department.

Let's suppose a 14-year-old boy is brought to the ophthalmologist's office complaining of a scratchy sensation from a foreign body in his left eye. The ophthalmologist examines the patient and discovers sawdust from a woodshop project to be the source of the discomfort. Luckily, there is no serious damage or laceration of the cornea. To code this procedure, choose the applicable E/M code (99201-99215) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Next choose an appropriate foreign-body removal code, 65205-65222, depending on the operative documentation.

You can also report code 99058 (Office services provided on an emergency basis), which can be found in the Medicine section of CPT, to indicate that the patient presented in the office on an emergency basis, says Lisa A. Bridges, CPC, ophthalmology coder with Woodhams Eye Clinic in Atlanta, "but not all payers necessarily recognize and reimburse for 99058."

For a Medicare patient, you would have coded the office visit with modifier -25 as well as the foreign-body removal if the E/M service was separately identifiable and sufficiently documented. Medicare doesn't recognize 99058 and won't pay more for in-office emergency treatments, so leave 99058 out of your in-office emergency service claims, Bridges says. In other words, you can't bill the patient separately for the emergency, after-hours or weekend charge, even if you obtain an advance beneficiary notice (ABN).

In many cases, patients presenting with traumatic eye injuries file under workers' compensation, says Diane Gleason, CPC, ophthalmology coder with Cadillac Eye Clinic in Mich. If it is a new episode and a new patient, she bills an office visit code with modifier -25 and the procedure code representing the surgical service rendered, she says. "Typically the evaluation and management service we bill is a low-level code, 99201 or 99202, for example," when the physician takes the patient's history and meets the documentation requirements for a separate E/M service.

The reasoning: When a patient is seen on an emergency basis, the physician is more likely to perform a "problem-focused" or "expanded problem-focused" examination of the area of injury or complaint, says Raequell Duran, president, Practice Solutions, Santa Barbara, Calif.

For workers' compensation patients, Gleason advocates having the physician dictate a letter to send in with the claim. Also, prior to seeing the patient, the office gets information from the patient's employer and insurance company to avoid trouble getting paid later, she says. "It is really important to get as much information up front as possible, especially in workers' compensation cases it makes it that much easier to get paid later."

Coding ophthalmologists' traumatic eye injury services provided in the emergency room is more complicated. Coding these facility emergency services depends on whether the ED physician was involved in the treatment and management of the patient.

Before attempting to locate the correct service codes when an ophthalmologist treats a patient in the ED, you first have to determine whether an on-duty ED physician was involved in treating the patient. An ophthalmologist can't bill for an ED visit if an ED physician is already charging for an emergency visit for a given patient, Bridges says.

ED codes are only billable once per day per patient, Gleason says. So if the ED physician has performed an evaluation of the patient and is already billing an ED visit code, you can't report an ED visit code to represent the services rendered by your ophthalmologist.

However, there are two scenarios in which the ophthalmologist should bill for ED treatments:

Scenario 1: The ED physician examines the patient and calls the ophthalmologist for a consultation. In this case, the ophthalmologist can bill for a consultation, 99241-99245, but only if all of the requirements for a consultation have been met including a documented request for the consultation. The Medicare Carriers Manual policy regarding consultations states the following regarding this type of patient: "In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physician's progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record."

Scenario 2: The ED doctor takes one look at the patient, decides not to perform an examination, and immediately transfers care to the ophthalmologist. Under these rare circumstances, choose from the ED visit codes, 99281-99285, and the office or other outpatient visit codes, 99201-99215, depending on the location of treatment.

In emergencies, physicians can find themselves working into the wee hours of the night, exceeding their regular office hours in these cases, "after-hours" codes found in the Medicine section of CPT are appropriate, Gleason says.

Three CPT codes reflect services rendered to patients after-hours: