Ophthalmology and Optometry Coding Alert

A July 1999 Ophthalmology Coding Alert article on billing Medicare patients out-of-pocket for refractions (page 54), stated that one practice routinely uses 99215 for an established patient comprehensive exam and 99204 for a new patient comprehensive exam. Although the story focused on refractions, the fact that a practice routinely bills such high-level codes drew criticism from Nicholas A. Zubyk, MD, FACS, of San Diego, Calif. If these are the routine codes used, these are extremely high, and in our area would certainly be cause for almost immediate audit on the part of our carriers, Zubyk writes. A 99215 requires significant and complex decision-making, which is rarely the case in most ophthalmology practices. I am surprised that the reviewers did not pick up on this, since this immediately raised an alarm bell for me.

Zubyk is right. Unless a practice happens to see all complex patients, it is not correct to use 99215 on a routine basis. In fact, its not correct to use 99212 on a routine basis, either. You must select a code based on documentation of services performed; medical decision-making is one of the three basic elements that goes into choosing the level of an evaluation and management (E/M) services code (history and examination are the other two).

Because the focus of the story was refractions, this practices routine use of certain codes went unremarked in the article. We regret any confusion that this may have caused.