Ophthalmology and Optometry Coding Alert

The rules say only one doctor gets to report 99281-99285 -- but it isn't always the ED doctor.

Knowing when you can report the ED or consultation codes for emergencies could be worth more than $180 per visit for your practice.

Ophthalmologists work hard dealing with eye injuries in an emergency department, but the payment they receive may not reflect their extra work. Medicare pays ophthalmologists less for treating patients in the ED than it does for treating them in the office because of the distinction between services performed in a facility setting versus a non-facility setting.

Payments for services performed in a nonfacility (such as the ophthalmologist's office) include extra reimbursement for practice expense. However, the physician work expense reimbursement is the same regardless of the setting, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Network Oversight, Mount Sinai Medical Center Compliance Department in New York City. "Since the physician is not bearing the practice expense in the facility setting, it stands to reason that reimbursement would be less," she explains.

When the ophthalmologist performs patient care services in the ED or an ambulatory surgery center, Medicare assumes that the facility will bill separately for their expenses, and the physician reimbursement is based on the facility RVUs.

Look to your Medicare Physician Fee Schedule to see the differences in reimbursement A physician service performed in a facility setting receives about a 50 percent reduction of the practice expense portion of the total relative value units, for an overall payment decrease of about 20 percent of the total Medicare allowable.

But can ophthalmologists report the ED codes (99281- 99285, Emergency department visit for the evaluation and management of a patient ...) in addition to the codes for their procedures?

Usually not, experts say, because typically an on-duty ED physician is involved in treating the patient. An ophthalmologist can't code for an ED visit if an ED physician is already charging for an emergency visit for a given patient.

Why not? ED codes are billable only once per day per patient. So if the ED physician performs an evaluation of the patient and bills an ED visit code, you can't report an ED visit code to represent your ophthalmologist's services on the same day.

However, there are two scenarios in which the ophthalmologist should bill for ED treatments:

Scenario 1: A patient with sparkler burns presents to the ED. The ED physician examines the patient and calls the ophthalmologist for a consultation. In this case, the ophthalmologist can bill for a consultation(99241-99245), but only if he meets all of the consult requirements -- including a documented request for the consultation.

Scenario 2: The ED doctor takes one look at the patient's triage notes, decides to call in the ophthalmologist, does not perform an examination, and immediately transfers care to the ophthalmologist.

Under these rare circumstances, choose from the ED visit codes (99281-99285) and the office or other outpatient visit codes (99201-99215), depending on the location of treatment. "If the patient requires admission to the hospital, the ophthalmologist will report the appropriate observation or inpatient codes," says Mac. "It is highly unlikely that the ED doctor will not provide at least an initial evaluation and exam of the patient presenting with an eye ailment, therefore it is highly unlikely that an ophthalmologist will ever report the ED codes."