Ophthalmology and Optometry Coding Alert

CMS Transmittal 1644, issued in August 1999, revised Section 15506 of the Medicare Carriers Manual to clarify that physicians may charge a consultation and go on to treat the patient. Carriers must pay for a consultation code (99241-99245) if three criteria are met: 1) the consultation must be provided by a physician whose opinion or advice regarding a specific problem is requested by another physician, 2) the request must be documented in the patient's medical record, and 3) the consultant must send a written report to the referring physician.
 
Carriers must pay for the consultation regardless of treatment initiation unless care is transferred, according to the revision. If care is transferred, the visit would not be a consultation, but rather an office visit (99201-99215) or an eye service (92002-92014). (For more on consultations, see page 82 of the November 1999 Ophthalmology Coding Alert.)

In choosing between an office visit, a consultation, and an eye exam code for a new patient, remember that consultation codes and new patient office visit codes require documentation of all three key components: history, examination and medical decision-making. This requirement does not exist for eye codes, a consideration when reimbursement rates between comparable codes are similar.
 
Note: We have given recommendations for levels of services in the following examples. But when you determine a level, documentation is essential. Regardless of the circumstances and work performed, if these are not appropriately documented, the levels of service will not be justified, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses.

Blurry vision, patient needs glasses: A patient may be referred for a problem that is not covered by insurance. For example, an internist refers a 67-year-old woman to an ophthalmologist for "blurry vision." When the patient arrives, she also asks to have her eyeglass prescription checked. The patient is informed that a refraction is a noncovered benefit with a separate fee, to be paid by the patient. The ophthalmologist, after an examination, finds all is normal, except that the patient has incipient cataracts and needs a new eyeglass prescription. He writes a note to the internist explaining his findings. Bill 99243 and 92015 for the refraction, which the patient will have to pay for. This problem doesn't meet the criteria for level four, so 99243 is the highest level that can be billed. The other coding choice is new patient eye code 92004. Consider carrier documentation requirements and reimbursement to choose between 92004 and 99243.

Cataracts: In another example, the same patient, after being examined by the ophthalmologist, is found to have significant cataracts. The ophthalmologist writes a note to the internist detailing his findings and his treatment plan. The physician and patient agree that cataract surgery is needed, and a surgery date is scheduled. In this example, more medical decision-making is involved, and the criteria for 99244 can be met, Roberts says. Use the consultation code instead of 92004 because the reimbursement is more appropriate for the extra work and overhead involved in providing the referring physician the consultation note. For either 99244 or 92004, the documentation must include an extended history of present illness; a complete review of systems; a complete past, family and social history; and a comprehensive examination. If an A-scan is performed on the same day, also report 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) with -RT (Right side) or -LT (Left side) appended.

No blurry vision, patient wants glasses prescription checked: A 59-year-old woman wants to have her eyeglasses prescription checked and asks her family practitioner who can do it. He refers the patient to an ophthalmologist, who sees the patient and, after examination, finds everything else normal. The ophthalmologist writes a new prescription for glasses. Do not bill a consultation code the family practitioner was not asking for an opinion, but was transferring the care of the patient's eyes and there was no medical problem. Report the E/M visit or the eye code with the refraction. Unless the patient has a vision plan, she must pay for the visit. Use 367.9 (Unspecified disorder of refraction and accommodation) to report the patient's refractive error unless a more specific refraction error code applies.

Retinopathy ruled out in newly diagnosed diabetic: A 66-year-old man, newly diagnosed with diabetes, is referred to an ophthalmologist by an internist to rule out retinopathy. The ophthalmological exam is negative for retinopathy. Code this visit 99243 because medical decision-making will not be high enough to qualify for a level four, even though the examination will include a dilated posterior segment evaluation. Link the appropriate diabetes diagnosis (250.0x) to the visit.

Retinopathy found, extended ophthalmoscopy performed, Medicare patient: In a related example, a 73-year-old man, newly diagnosed with diabetes, is referred by the internist to the ophthalmologist. The ophthalmologist finds retinopathy. Code 99243 plus 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial). For Medicare, do not bill 99244 with 92225 or 92226 ( subsequent) because that would be billing twice for the detailed examination of the posterior segment the part of the examination in which the physician looks for retinopathy, Roberts explains. "When documentation goes straight from the anterior segment to dilation to a drawing, that means the posterior segment has already been coded if the extended ophthalmoscopy [EO] code is used," she says. When the physician bills the work for the drawing as EO (92225-50 [Bilateral procedure]) that work cannot be counted toward the level of examination. This is less than a comprehensive examination, which includes the posterior segment. Therefore, when you bill for bilateral EO on the same day as a consultation or new patient E/M service, the maximum level of examination that counts toward determining a level is "detailed," which is a third-level service. This typically results in 99243 instead of 99244. If the retinopathy is proliferative or there is focal bleeding, and laser treatment will occur, the ophthalmologist may order fluorescein angiography (FA) (92235). If the FA is not conclusive, the ophthalmologist may also order an ICG test (92240, Indocyanine-green angiography [includes multiframe imaging] with interpretation and report).

Retinopathy found, extended ophthalmoscopy performed, non-Medicare insurance: A 53-year-old woman recently diagnosed with diabetes is referred to the ophthalmologist to rule out retinopathy. The ophthalmologist performs the examination and EO (92225). In this case, file 99244. Many HMOs and PPOs will not pay for EO separately from the consultation codes.

Retinopathy ruled out, but glaucoma and early cataracts found in newly diagnosed diabetic, Medicare patient: A 68-year-old man newly diagnosed with diabetes is referred to the ophthalmologist to rule out retinopathy. In this case, the patient does not have retinopathy but has elevated intraocular pressure and early cataracts. Code 99244 and visual field testing (92081-92083, based on the extent of the test). Link 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline findings) and 366.12 (Senile cataract; incipient cataract) to the visit because those are the medical conditions found. The reason for the visit was diabetes, but do not use a diabetes diagnosis on the claim form unless no other definitive diagnosis is found.

Child has vision problems, needs glasses: A pediatrician refers an 8-year-old girl to the ophthalmologist because the patient reported difficulty seeing the blackboard. The ophthalmologist prescribes glasses. Bill eye code 92004 because there is no medical condition that warrants the consultation codes.

Child has vision problems, has medical condition: A pediatrician refers a child who has trouble reading from the blackboard. The ophthalmologist discovers that the child has amblyopia. Treatment consists of patching the eye that the brain prefers, forcing the brain to recognize the images coming from the amblyopic eye, and a prescription for eyeglasses that corrects the weaker eye as close as possible to 20/20. File 99244 for this visit.