Ophthalmology and Optometry Coding Alert

Most ophthalmologists use the outpatient E/M codes far more often than they bill hospital visits, but eye surgeons do see inpatients regularly. If you've got questions about hospital-based E/M coding, we're here to help.

Background: Last month, Ophthalmology Coding Alert shared the news that eye physicians logged among the highest outpatient E/M visit error rates based on the latest CMS Comprehensive Error Rate Testing report. Several readers wrote in and asked our editors follow-up questions about coding E/M visits for both office and hospital visits, and today we've got the answers to ensure that you're reporting inpatient services accurately every time.

FAQ 1: When Can You Report 99221 and 99238 Together?

Question: Can we bill 99221 and 99238 on the same day under any circumstances? For example, the admitting physician saw the patient in the morning (99221). Then, later that afternoon, the admitting physician returned to discharge the patient (99238). Are there any modifiers we can use?

Answer:  No. According to the Correct Coding Initiative (CCI) Edits, you cannot bill 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...) together with 99238 (Hospital discharge day management; 30 minutes or less). This CCI edit includes a modifier indicator of 0, which means you cannot use a modifier to override the edit under any circumstances.

Although 99238 is a hospital discharge code, in your case, it is not the appropriate choice. According to CPT^®, you should only use 99238 to report services provided to a patient on the date of discharge "if other than the initial date of inpatient status."

Since the physician in this example admitted and discharged the patient on the same day, CPT^® directs you to choose a hospital service code such as 99234, 99235, or 99236 rather than the 99221/99238 combination.

FAQ 2: What's the History Requirement for 99232?

Question: We have met the exam requirement for 99232, but not the medical decision-making element. Now our code choice hinges on the history. How do we determine which history level is required for 99232?

Answer: If you are using history as one of the two elements in your code selection (between history, exam, and medical decision-making), code 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...) requires an expanded problem-focused interval history. This should include a brief HPI (one to three elements) and problem pertinent review of systems (ROS) or an inquiry about the system directly related to the problem(s) identified in the HPI.

Best Practice Guideline:  If you use medical decision-making as one of the two components in selecting subsequent services, this will satisfy medical necessity that most payers use as their overarching criterion for E/M service.

FAQ 3: Can You Differentiate Inpatient From Observation?

Question: Our ophthalmologist admitted a patient to the hospital at 10:30 a.m. A different ophthalmologist, also from our practice, discharged the patient at 3:30 p.m. The admitting physician wants to bill an inpatient code, while the discharging physician wants to bill an observation code. Which is correct?

Answer: The answer here depends on a number of factors, including whether the physicians are billing under the same tax ID number (TIN), if the patient was admitted as an inpatient or for observation, and, if the patient was admitted for observation, the length of time the patient spent under observation.

If the physicians in question are billing under separate TINs and assuming this was an inpatient admission, then the first provider would bill an initial hospital care code from 99221-99223, and the second provider would bill from 99238-99239 (Hospital discharge day management ...) for the corresponding discharge.

You would document a patient admitted and discharged by physicians billing under the same TIN, however, with 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), which covers both inpatient and observation statuses.

But if the patient was admitted to observation, you would bill using 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...) for physicians billing under the same TIN, while the first provider would bill 99218-99220 and the second 99217 (Observation care discharge day management ...) when billing under separate TINs.

Why? Medicare and payers who follow its guidelines abide by the CMS decision that when "a patient receives observation care for less than eight hours on the same calendar date," the physician should report "from CPT^® code range 99218-99220." (Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf).