Ophthalmology and Optometry Coding Alert

Although the office-based E/M codes were overhauled earlier this year, that wasn’t the case for emergency department (ED) codes. In fact, the differences between the code sets are now more obvious than ever. And if your ophthalmologist ever performs services in the ED, you should prep now for how to report them.

Why? While there are similarities between the two code sets, there are also several key differences you’ll need to know in order to stay on top of your ED E/M claims.

Check out these mythbusters to get the straight dope on ED E/Ms.

Myth 1: Office E/Ms and ED E/Ms Use the Same Code Set

This might seem basic, but some coders have made the mistake of using office E/M codes 99202-99215 (Office or other outpatient visit for the evaluation and management …) in an ED setting.

Do this: Choose one of the codes from 99281-99285 (Emergency department visit for the evaluation and management of a patient …) to code for ED E/M services.

The ED codes are still chosen based on the components of history, exam, and medical decision making (MDM). So if your ophthalmologist is evaluating a patient in the ED, make sure you select the right code based on these criteria. In addition, all three elements must be met (rather than two of three, as the office codes formerly required) to pick a particular code.

Example: The ophthalmologist is called to evaluate a 7-year-old patient in the ED who fell off a playground and scratched her cornea. The ED physician thinks the problem may be deeper than a superficial injury, so they ask the eye care specialist to examine her. The ophthalmologist documents an expanded problem focused history, an expanded problem focused exam, and medical decision making of low complexity.

Although the history and exam would qualify for 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/ or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity), the MDM of low complexity does not meet the requirements of 99283.

Therefore, you must instead report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity) for this visit.

Myth 2: You Have to Know Patient Status for ED E/Ms

All patients are new in the ED; there is no such thing as an established ED patient. In addition, an entirely new workup and chart are required for each new ED visit. Therefore, even if a patient presents to the ED every day, you won’t ever consider them established, so there are not separate code sets for new and/or established patients. You’ll just report a code from the 99281-99285 set.

Myth 3: You Can Code Based on Time in the ED

Unlike office E/M codes, time is not a factor in ED E/M services. Therefore, none of the ED codes have time ranges associated with them, and you can’t use prolonged service codes in the emergency setting.

“Prolonged services require that an E/M service that includes a typical time must be billed before the prolonged services can be added on, and that prolonged service must exceed the typical time in the E/M code by 30 minutes before it can be added,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

According to the E/M Guideline Revisions that the AMA released in 2021, “The use of the time-based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT® codebook.” The 99281 through 99285 code set does not have specified times in its descriptors.

In fact, time is not measured in ED coding unless you are coding a critical care case (99291-99292).

Bonus Myth: Incident-To Is an Option in the ED

The concept of incident to does not apply in the hospital setting, and this includes services provided in outpatient departments like the ED. Therefore, if your physician assistant or nurse practitioner provides services in the ED under the supervision of the physician, you cannot report their services under the incident to guidelines.