Ophthalmology and Optometry Coding Alert

Hint: Timing is everything.

As technology advances, so does the practice of medicine. Patient management using digital health tools — such as patient portals that allow patients and physicians to connect asynchronously — is one such example. But are you up on this latest way to capture your eye care provider’s work behind the scenes?

Protect your providers from losing out on hard-earned pay due to billing oversights by brushing up on the digital evaluation and management (E/M) codes and rules for capturing these non-face-to-face services. And find out what, if anything, might change in the years ahead.

Get To Know the E-Visit Codes

An e-visit is a patient-initiated digital encounter that takes place through a secure online portal. There are two sets of codes. One is for encounters between a patient and physician:

• 99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
• 99422 (… 11-20 minutes)
• 99423 (… 21 or more minutes)

The other set is for encounters between a patient and another qualified nonphysician healthcare professional (QNHP):

98970 (Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)

• 98971 (… 11-20 minutes)
• 98972 (… 21 or more minutes)

Remember 7 Is the Magic Number

The potentially tricky part about these codes is keeping track of time to determine whether to report a code, and if so, when to report the service.

Key: These codes are exclusive to established patients and may include time spent interacting with the patient for up to seven days. That means your providers must document the time associated with each interchange so that you can add up the time spent at the end of the seven-day period. In other words, you won’t bill for these encounters as soon as they occur.

Note: “If the inquiry is related to a surgical procedure within a global period, then the service is not reported. The provider therefore must keep a permanent record on file. Other rules apply and are listed in the CPT^® manual,” says Natalie Ruggieri-Buzzelli, CPC, CGSC, HIM coding specialist at the Hospital of the University of Pennsylvania.

Employ NCCI Edits To Navigate 7-Day Rule

If a patient initiates an online digital inquiry for the same or a related problem within seven days of a previous E/M service, you shouldn’t report the online digital visit. CPT^® also specifies that if a separately reported E/M visit occurs within seven days of the online digital service’s initiation, then the work the physician or QHP devotes to the online digital E/M service should be incorporated into the separately reported E/M visit.

Key: CPT^® considers that digital service to be part of a related E/M visit if the digital service falls within seven days of the encounter.

For further clarification of this seven-day rule, turn to the National Correct Coding Initiative (NCCI) edits.

You’ll see that while 99421-99423 are Column 2, or component, codes to 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …), the edit pairs all have 0 modifier indicators, meaning that you cannot use an NCCI-associated modifier to unbundle the services.

Note these exceptions: Codes 99422 and 99423 are not paired with new patient office codes 99202-99205. For the established patient E/M codes, things are a little more complicated, as 99421-99423 are not paired with 99211, while only 99421 is paired with 99212.

Conversely, when 99422-99423 are the Column 1, or comprehensive, codes, NCCI has only paired them with 99211 and 99212, with each pair having a 0 modifier indicator. However, as a Column 1 code, 99421 only has a 0 indicator with 99211. The codes are not paired with any of the other 99202-99215 codes.

Why? “When 99421-99423 are paired up with the 99202-99215 codes, some edit pairs have the 99421-99423 codes in Column 1, and some edit pairs have them in Column 2,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “I believe [the Centers for Medicare & Medicaid Services] CMS has decided which code is the Column 1 code in any given combination based on which of the two codes in the pair has a higher work relative value unit [RVU], indicating a more extensive service,” Moore continues.

Coding tip: Despite these exceptions, there are still many instances where 99421-99423 and 99202-99215 are not code pairs. This means that you will be able to claim an online digital E/M with an office visit on the same date of service. To do so, you must have documentation that the two services are not related in any way.

Preview This Example, Pay Attention to Particulars

Let’s say an established patient contacts your ophthalmologist through their patient portal two weeks after having discussed treatment options for persistent allergic conjunctivitis. The doctor had previously recommended avoiding possible irritants, cool compresses, and artificial tears, and a check-back if there’s no improvement. After 10 days, the patient reports little has changed. The doctor reviews the information and prescribes a trial of topical steroid eye drops and oral antihistamines.

This is a situation where you can bill 99421 (if the encounter lasted 5-10 minutes), but make sure the physician documentation includes the following:

• Proof the encounter was patient-initiated
• Patient location
• Chief complaint /reason for the encounter
• Justification for services
• Pertinent history and exam
• Medical decision making
• Applicable diagnoses
• Duration of encounter(s) within the seven days

Expect Digital Code Pay To Be Here To Stay

While these codes have taken some getting used to because of the documentation requirements, the good news is that there’s probably no reason to expect they’ll go away or that CMS will stop paying for them. “I fully expect both of those code families to be covered and paid by CMS, just as they are now,” says Moore. Service codes 99421-99423 were added to CPT^® prior to the pandemic.