Ophthalmology and Optometry Coding Alert

Scenario: A patient calls her ophthalmologist, who is part of a large group practice, to make a routine appointment, telling the receptionist that she has had a few bothersome problems lately, including occasional flashing lights. The history reveals that the patient has been having flashes and floaters for several weeks. Upon examination, the ophthalmologist discovers a retinal tear, and refers the patient to a retinologist who is in the same practice. The retinologist performs surgery the same day. How would the coding staffer for this practice code for the services provided?

One big question here is whether you can bill for both the visits with the general ophthalmologist and the retinologist on the same day. If they were in different practices, you could, but this question becomes complicated because they are in the same group.

You can indeed bill for both physicians with many insurance plans, according to M. Robin Fox, HCRM, director of reimbursement for Eye Centers of Florida, a 30-provider multi-office practice based in Ft. Myers, FL. If the ophthalmologist performs a routine exam and learns of the complaint of flashes and floaters during the course of the exam, the ophthalmologist would bill for an eye exam, says Fox. You would use either an E/M office visit code (99201-99215) or an eye code (92002, 92004, 92012, or 92014). The retinologist would then bill a consult code (99241-99245), says Fox.

But theres a lot of controversy about billing a consult code within a single practice, Fox warns. We believe that you can do it if the physician is a sub-specialist, such as a retinologist, says Fox, noting that with Medicare in Florida, there usually wont be a problem doing this. With some private carriers and some Medicare carriers and Medicare HMOs, however, you will not get paid for both encounters, she states.

In that case, you would want to get paid for the consult only, since it pays at a higher rate. You would use the referring ophthalmologists UPIN as the referral, but you wouldnt bill for the visit itself, says Fox.

Consult or Transfer of Care?

The use of a consult code for the retinologist when billing Medicare is further complicated by a recent update in the Medicare Carriers Manual (MCM) to Section B3 15506, regarding consultations (99241 - 99275), says Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY. This section states, When the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally (i.e., a request to evaluate and treat), the receiving physician may not bill a consultation. He or she bills a visit. The rule is then further complicated by the instruction to [...]