Ophthalmology and Optometry Coding Alert

Big changes are coming in January — prepare now so you’re ready.

In less than a year, your E/M coding will change dramatically, thanks to updates that are on deck to take effect January 1, 2021. You can get ready now by becoming familiar with how eye care coding will be affected.

1. Prepare to Say Goodbye to 99201

Many eye care practices consider 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) to be a quick fallback code to evaluate a new patient with a straightforward diagnosis.

Effective January 1, 99201 will be eliminated, prompting you to select from 99202-99215 for outpatient visits. However, in cases when you would have reported 99201, you may be able to bill the ophthalmological services code 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) instead if your documentation supports the requirements.

Example: You see a new patient and document a problem-focused history and straightforward medical decision making (MDM). You also document an external ocular exam and an adnexal exam, and you check the patient’s visual acuity. In this situation, you’ll report 92002, precluding you from having to consider the absence of 99201.

Watch out: Be sure to review any changes that may take place next year with the requirements for 92002, says Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology in Canandaigua, New York. “Currently, 92002 requires initiation of a diagnostic procedure and treatment program, so these elements must be within the documentation as well to support medical necessity.”

2. You’ll Lean More Heavily on MDM

Eye care coders are acutely aware of the importance of documenting history and exam levels so they can select the appropriate E/M code level — but that won’t be the case next year. In 2021, you’ll need to document a medically necessary and clinically appropriate history and exam, but these elements will not guide your code selection. Instead, you’ll choose your E/M code level based on either time spent or MDM.

To that end, you’ll need to prepare for the descriptor to change “number of diagnoses or management options” in the MDM section to “number and complexity of problems addressed.”

Example: This change means that even if the physician is dealing with just one diagnosis, they’ll still get credit for addressing the comorbid conditions. For instance, a patient may have glaucoma which the ophthalmologist is actively treating, but the physician can benefit from also addressing how the glaucoma medication will impact the patient’s chronic obstructive pulmonary disease (COPD), even though they aren’t actually treating that condition. This is likely to have more weight under the new guidelines.

Under today’s guidelines, it’s been unclear whether you could consider the COPD in the patient’s MDM calculation if the ophthalmologist asks, “How is your breathing?” and uses the answer to guide selection of the most appropriate medication options. In 2021, it appears that you’ll have more credit for addressing these types of questions.

It will remain to be seen what the details are surrounding what you’ll need to document in this situation, but eye care coders are welcoming the new verbiage and how it will affect your code choice selection.

In addition, the reliance on MDM will justify the removal of 99201, as noted in our first point above. Since both 99201 and 99202 rely on straightforward MDM, if a new patient presents with straightforward MDM and you prefer not to report an ophthalmological services code such as 92002, you can instead report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…).

3. Tally That Time

As we already know from the Medicare Physician Fee Schedule (MPFS), beginning on January 1, 2021, Medicare plans to let you choose E/M levels based on the level of MDM your provider engages in during the encounter or the total time of the encounter.

This has led CPT^® to replace the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the times for each of the codes. The typical time currently included in the code descriptors only reflects face-to-face time. But since most office visits have some pre- and post-visit time involved, too, the change to total time on the date of the encounter will also include pre- and post-visit time that day.

Keep an eye on Ophthalmology and Optometry Coding Alert to get more information as insurers and CPT® release additional details about how the new E/M code rules will work in January.