Ophthalmology and Optometry Coding Alert

Maybe the patients parents both have cataracts. Maybe a best friend just had cataract surgery. Or maybeas in the case described in the June issue (page 43 of Ophthalmology Coding Alert), an optometrist told the patient she had a cataract. In any event, the ophthalmologist looks and doesnt find one. This makes for some confusion when it comes to coding. In the story in the June issue, it was explained that if a patient comes in with no complaints at all, you cant bill Medicareeven if you do find something. Thats why its so important for the technician to do a thorough interview before the ophthalmologist even sees the patient. The article also stated you cant commonly use the diagnosis code of cataract for this patient.

Well, Larry Patterson, MD, of Eye Centers of
Tennessee in Crossville, disagrees. Even if they see nothing there, I would code it as a cataract, says Patterson. You code the visit as being the reason for the patient being there. Thats the reason.

Some patients do, indeed, come in and say that they want to be checked for a cataract. If I find none, and I tell them to come back in a year and check again, then the diagnosis code for the next year is cataract, he says. But if they just wonder if they might have a cataract, thats routine, and that is not billable. If an optometrist actually tells a patient that she has a cataract, the patient shouldnt be penalized just because the optometrist was wrong, Patterson believes. I would use the cataract diagnosis for what the OD says, even if its not right.

Medicare has made it very clear that reimbursement is based on a patients complaint, notes Patterson. But just because a patient doesnt have any vision complaints doesnt mean the diagnosis code still would be for a cataract, he says. I put cataract: non found in the chart, he added.

Vickie Wadsworth, office manager for Northern Wyoming Ophthalmology of Cody, WY, thinks that its likely that the ophthalmologist would find something wrong. First of all, there are different extremes of cataracts, she says. Many physicians do not realize there is an ICD-9 code for incipient cataract (366.12). When the cataract is that negligible, many physicians dont want to alarm the patient with a cataract diagnosis and so dont include the findings in the medical record. Secondly, its most likely not going to be a normal eye exam anyway. There could be diagnoses other than cataracts. The diagnosis codes should be for whatever the ophthalmologist does find in the exam. And Wadsworth stresses that the diagnosis does not have to be the same as the chief complaint as long as there is a chief complaint.

Be Cautious of False Claims

Unfortunately, coding something which a patient does not have is a false claim to an insurance company, says Lise Roberts, vice president of Healthcare Compliance Strategies in Syosset, NY, and an expert in ophthalmology coding, in response to this dilemmaand it is a major dilemma for ophthalmologists. When you submit a diagnosis code, it means the patient does have that condition, Roberts says. If the patient comes in for a valid complaint, such as theyve been told by an optometrist that they have a cataract, but there truly is no cataractnot even a very early onethere are no visual complaints and there is no other diagnostic condition found in the course of the evaluationthen the service is a screening service for a suspected condition, the consultant relates. Its correct, she adds, that the patients reason for the visit determines whether the service is medically necessary or not, but that doesnt necessarily make it okay to submit a false diagnosis code.

There are times when odd diagnosis codes must be used, Patterson concedes. For example, sometimes patients want to know about a gray spot they have on their eye. Its just a scleral thing, he says. But they get worried about it, so they come in. Or sometimes, a patient will get something in his or her eye, rub it, and notice there is a bump. They get scared, and come in, says Patterson. All they see is the caruncle, but they are worried. For some of these cases, especially if they are repeats, Patterson uses the code for worried well (V65.5). This code is often not paid by carriers.
Physicians sometimes use it when they want to discourage a patient from abusing their services.

There are also a number of diagnosis codes for subjective visual complaints: 368.10 (subjective visual disturbance, unspecified), 368.11 (sudden visual loss), 368.12 (transient visual loss, such as concentric fading or scintillating scotoma), 368.13 (visual discomfort, such as asthenopia, eye strain and photophobia), 368.14 (visual distortions of shape and size, such as macropsia, metamorphopsia, and micropsia), 368.15 (other visual distortion and entoptic phenomena, such as photopsia, visual halos, and the refractive diagnosis of diplopia and polyopia), and 368.16 (psychophysical visual disturbances, such as visual agnosia, disorientation syndrome, and hallucinations). You could also use 368.8 (other specific visual disturbances, such as blurred vision not otherwise specified), although this is a non-specific code.

The correct diagnosis code, says Roberts, would either be V71.8 for observation and evaluation for suspected conditions not found; other specified suspected conditions or V80.2 for special screening for neurological, eye and ear diseases; other eye conditions: cataract, congenital anomaly of eye, senile macular lesions. However, many Medicare carriers will deny payment if the correct ICD-9 code is submitted, because they consider screening examinations as routine services, Roberts concedes. Both the physician and the patient are in a proverbial Catch-22, she says. In todays heated environment of government focus on Medicare fraud and abuse, the best advice to the physician is to use the appropriate diagnosis codes, and to have the patient sign an advance beneficiary notice advising them that the service will most likely be denied for lack of medical necessity and agreeing that they will pay for the service when it is denied, Roberts recommends.

Gregory L. Schnitzer, RN, CPC, audit specialist with the Office of Audit and Compliance at the University of Pennsylvania in Philadelphia, agrees with Roberts. If there are absolutely no signs or symptoms other than something another provider says, and the doctor cant find anything in an exam, a cataract diagnosis would not be appropriate. What should happen, says Schnitzer, is that the ophthalmologist should bill the patient. If another diagnosis is found, however, it would be correct to use that diagnosis for the visit, even if the patient didnt have a complaint. Its only with diagnostic tests that you cant use the diagnosis after the fact, he says.

Still, there is a lot of logic in Pattersons theory of coding the complaint, rather than having to write off the visit because no diagnosis is found. In defense of fairness, if someone comes in with no complaint and it turns out he or she has a serious sight-threatening problem, and we cant get reimbursed for that, then we should get reimbursed if the patient comes in with a complaint and we dont find something, he says. They [Medicare] cant have it both ways. (But they do have it both ways.)

Procedures Codes Outlined

1. If the patient referred herself to you based on the optometrists statement that she had a cataract, but you didnt find anything, and if the patient is referred by a colleague for an opinion, you would bill a consultation (99241-99245) for the visit, our sources agree.

2. You could also bill a confirmatory consultation (99271-99275).

3. These codes are also called second opinions.

Remember that a consultation, whether initial or confirmatory, is to be used when you are only expected
to provide an opinion, and no therapeutic services. (For more information on consultations see Get Compensated for Consultations: Document and Code Appropriately in the March 1999 issue of Ophthalmology Coding Alert on page 17.)