Ophthalmology and Optometry Coding Alert

Ophthalmologists and optometrists, in association with their respective eye-care groups, make monthly or semimonthly professional visits to a variety of nursing facilities. Coding these visits depends on the services performed and the type of nursing facility in which the patient resides.
 
In most cases, an optometrist goes to a nursing home to conduct routine exams; an ophthalmologist or subspecialist will visit a facility only if a patient requires medical attention. The purpose of the visit determines the code selection, not which professional performed the service.
 
The ophthalmologist and optometrist may choose one of the following codes: nursing facility (99301-99313), domiciliary (99321-99333), eye (92002-92014) or outpatient services (99201-99215). Inpatient codes for nursing-facility visits may be used only if the nursing facility is an acute-care facility within a hospital. 
 
There are two kinds of nursing-facility services (99301-99313) and domiciliary, rest-home or custodial-care services (99321-99333). The nursing-facility codes are for services provided within a facility in which 24-hour medical services are available. Domiciliary, rest-home and custodial-care codes are for nursing homes that provide room and board, as well as personal assistance. Domiciliary codes are used only when the nursing facility does not provide medical assistance to its residents.

 
The nursing-facility medical director or nursing staff identifies patients with chronic conditions that require regular monitoring for routine eye visits. For example, a visit would be considered routine if a glaucoma patient who is managed by medication needs to be seen every four to six months or if a patient with slowly progressing cataracts needs to be seen only once a year.
 
In these instances, code selection depends on which type of service the ophthalmologist or optometrist performs. Professional services are also contingent upon the type of medical equipment available at the nursing facility. For instance, if the nursing facility does not own a slit lamp and, as a result, an anterior segment examination cannot be performed, lower-level exams may be appropriate. If the nursing facility owns a slit lamp or if the ophthalmologist or optometrist brings his or her own equipment to the nursing facility (e.g., slit lamp, funduscope or an indirect ophthalmoscope), higher-level exams can be billed.
 
"Code what is being done," says Lise Roberts, vice president of Health Care Compliance Strategies, a company based in Jericho, N.Y., that develops interactive compliance training courses. In the past, eye codes have required less documentation than E/M codes, but this is not necessarily true for the exam, Roberts says. Some carriers' local medical review policies (LMRPs) for eye codes are quite prescriptive about what is required in the exam.

 
Rather than using nursing-facility codes for routine visits, coders use the low-level eye codes 92002 (ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) for new patients, and 92012 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) for established patients.
 
"When we go into nursing homes, we bill the eye codes," says Melissa K. Duchak, CPC, a coding consultant and practice administrator for ophthalmologist Bruce E. Kanengiser, MD, based in Piscataway, N.J. "My problem with the nursing-home codes is that, for us, there is too much documentation involved. I don't honestly feel an eye doctor is going to hit what it takes for those codes during these routine checks," Duchak says, adding that these visits merit 92002. "You could also bill 99202 (office or other outpatient visit for the evaluation and management of a new patient, which requires an expanded problem-focused history and examination, and straightforward medical decision-making) or 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires a problem-focused history and examination, and/or straightforward medical decision-making). But again, because of documentation, I prefer the eye codes."

 
If an ophthalmologist or optometrist visits a patient who requires medical attention in a nursing facility, eye codes should not be used. In this instance, use nursing-facility codes (99311-99313) or office visit codes (99201-99215). "I prefer the nursing-home codes," says Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc., a coding consultancy based in Spring Lake, N.J. "Use nursing-facility codes when the patient does not require a comprehensive assessment and has not had a major change of medical status." For example, when an ophthalmologist conducts a four- to six-month interval follow-up of a glaucoma patient who does not require a dilated funduscopic examination, nursing-facility codes should be used.
 
"If it is a nonemergency visit as well as a medical visit, bill using the nursing-facility codes," agrees Terry Fletcher, CPC, CCS, a coding consultant based in Aliso Viejo, Calif. Make sure to bill the subsequent nursing- facility-care codes (99311-99313) and not the comprehensive nursing-facility-assessment codes (99301-99303),  Roberts warns. "The nursing-facility codes are acceptable for ophthalmologist or optometrist visits only if the subsequent codes are used," she says. "The comprehensive codes are for the admitting physician only. This coding protocol is similar to inpatient codes wherein the initial inpatient visit codes are designated for the admitting physician's use." For instance, if it is the physician's first visit to the patient -- and the location of the service is within a 24-hour nursing-care facility, intermediate-care facility or long-term-care facility -- other outpatient visit or new patient codes (99201-99205) may be appropriate in lieu of the subsequent nursing-facility-care codes.

 
For an emergency, the ophthalmologist has a choice of billing an office visit code, a subsequent nursing code or an eye code, depending on where the service is rendered. Proper CPT coding states you can bill the emergency code (99058) and, if appropriate, add an after-hours code (99050-99054) to the nursing-home code or the office visit code. 
 
However, you will not be reimbursed for these extra codes because Medicare does not recognize them. The carrier will not pay for anything other than the patient's transport to your office.
 
An example of an emergency is a patient who suddenly develops flashes and floaters with a sudden loss or decrease in vision -- a sign of possible retinal detachment -- and needs to be seen by an ophthalmologist immediately. If the patient is brought to the ophthalmologist's office, bill an office visit (99201-99215) or an eye code (92002-92014), depending on the diagnostic problem(s), examination performed, documentation and LMRPs. If the physician goes to the nursing home, use nursing-facility-care codes (99311-99313) depending on the diagnostic problem(s), examination performed, documentation and LMRPs.
 
When selecting codes for nursing-facility visits, ophthalmologists can compare RVUs and their carriers' documentation requirement. The codes discussed in this article, with the RVUs, are 99201 (0.93), 99202 (1.62), 99203 (2.39), 99204 (3.47) and 99205 (4.38) for new patient office; 99212 (0.94), 99213 (1.32), 99214 (2.06) and 99215 (3.06) for established patient office; 92002 (1.86), 92004 (3.15), 92012 (1.59) and 92014 (2.29) for eye services; and 99311 (0.87), 99312 (1.40) and 99313 (1.95) for subsequent nursing-facility visits.