Documenting a Fourth-Level Visit for a Cataract Evaluation
Published on Mon Mar 01, 1999
What do I need to bill a fourth-level visit? is a question many ophthalmologists askusually in desperation, after having spent an extensive session with a new patient who is being evaluated for cataract surgery. A blend of the third- and fourth-level new patient Evaluation and Management (E/M) Service RVUs (99203 and 99204) corresponds roughly to the comprehensive eye code (92004) RVU.
Ophthalmologists really want to know what documentation is required to enable them to bill a 99204.
This scenario covers more than 70 percent of my practice, says Hemant Shaw, MD, an ophthalmologist who practices in Middletown, NJ. I see a new patient for a cataract evaluation. The patient has had poor vision in both eyes for the last four months, and cant drive at night. I do an ROS [review of systems]. She has no eye pain, no discharge, no tearing. I ask about allergies and medications. I do a complete exam of the visual system. I spend time talking with the patient about the risks, alternatives, and benefits of cataract surgery. All total, I spend about 45 minutes with the patient. I think this should be a 99204. What do I need to bill 99204? And if it were an established patient, what would I need?
We talked to two experts about how ophthalmologists should chronicle to reach a level-four E/M visit under the 1997 documentation guidelines. However, both give the same caveat: Each patient is an individual, and must be individually reviewed. When it comes to Medicare audits, anyone using a cookie-cutter approach is playing a dangerous game, and theres a strong chance that the Office of Inspector General (OIG), and not you, will win. So use their recommendations as guidance only. Dont try to make your patients fit into a higher level just because you think youve earned the money; your auditor may disagree.
Start the Exam
The exam is the easiest item to document, because ophthalmologists have been doing this for years, says Heather Freeland, a consultant with Rose and Associates, a Duncanville, TX-based consulting firm specializing in Medicare reimbursement and compliance in ophthalmology. For a new patient, you need 12 ophthalmological elements and a neurological (mental status exam) element to justify a 99204. (See box in next column for elements.)
Its important to note that the exam does not include any procedures. The eye exam only includes things that cannot be billed separately, says Freeland. For example, if you check pupils, lids, conjunctivae, cornea, iris, lens, and do tonometry, fundus photos, visual fields, and an A-scan, how many elements are there for the exam? Six. Not 10.
Fundus photos, visual fields, and the A-scans are special ophthalmological services and are not included in the exam.
Each special [...]
