Ophthalmology and Optometry Coding Alert

The office and other outpatient consultation codes (99241-99245) are to be used when a physician or other appropriate source sends a patient to your ophthalmology practice for evaluation, opinion and advice, which may include your initiation of treatment prior to returning the patient to the original physician or other appropriate source. Does this mean that the first time you see a patient at the request of another physician that you can always charge a consultation code? No, says Ellen Kaiden, administrator of Westwood Ophthalmology Associates, a two-provider practice in Westwood, NJ. A consult code is appropriate, she explains, if you are asked by another doctor to examine his patient and report on your opinion and advice only, and there is no intent of the requesting physician to transfer to you the specific care of the patient.

Consultation codes pay better than office visit or eye codes, which is why it is important that ophthalmology practices understand when they are appropriate to use. But it can be confusing, because some ophthalmologists use the term consult interchangeably with referral. However, HCFAs Medicare views consult as having a distinct meaning.

Transfer of Care vs. Consult

If your ophthalmologist has been asked to see a patient, and initiates treatment and then continues to see that patient for follow-up for the specific conditionwithout a documented intervening discussion in which the requesting physician asks your ophthalmologist to take over the managementthe likelihood is that the initial service will be viewed by an auditor as a transfer of care, not as a request for a consultation, says Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY. HCFA understands that the receiving ophthalmologist may still write letters to the requesting physician to update him or her on the care of the patient, but this is viewed by HCFA as appropriate coordination of care with another provider and not a fulfillment of a request for a consultation by itself, Roberts explains. It is the intent of the physician requesting the service [i.e., the sending physician] which must be divined from the available documentation by the auditor. For this reason, many ophthalmologists have adopted a policy of requiring a written consult request from originating physicians. This makes the intent of the requesting physician explicit. If the request is to see and treat, you should not use the consult codes, she says. If the request is to see and render an opinion and advice prior to treatment, the consult codes are appropriate. Keep in mind that it is the requesting physician who will determine the ophthalmologists course of action in this situation.

When we do a consultation, the doctor spends more time, has to write everything down, and has to report back to the physician requesting the consult every time he sees the patient, says Kaiden. Its much more labor-intensive than an office visit.

Confirmatory Consultations

Kitty Timmes, COMT, office manager for Joseph J. Timmes, Jr., MD, FACS, in Annandale, VA, says that a consultation code is used the first time her practice sees a patient at another physicians request, since the practice, which is about half Medicare and half PPOs (very few HMOs), is limited to retinology. The requesting physician is usually an ophthalmologist, says Timmes. This may facilitate acceptance of the consultation codes by insurance companies.

Medicare does not distinguish between the sub-specialties of ophthalmology, notes Roberts. All ophthalmologists are the same specialty designation whether they are a sub-specialist or not. This means that if the retinologist sees the patient on the same day as the general ophthalmologist for the same diagnostic condition, there may be some denials of the second service, because Medicare deems it concurrent care, she explains. Also, just because the practice may represent a certain subspecialty, this fact does not in and of itself validate the service as a consultation for Medicare patients. This runs contrary to a view widely held by many ophthalmology sub-specialists, Roberts notes. As explained above, if the intention of the physician requesting the sub-specialist to see the patient is that the sub-specialist will see and treat the specific problem, then the service is considered a transfer of care and not a request for consultation. On the other hand, a consultation can be established by the presence of the 3 Rs: Request, Referral, Report. Note that treatment is not involved in this trio.

Sometimes a first visit by a patient under these circumstances does not warrant an outpatient consultation code (99241-99245), but does warrant a confirmatory consultation code (99271-99275), says Timmes. For example, if a patient contacts the sub-specialist himself for a second opinionperhaps because he knows he has a retina problem, and he picks the retinologist out of the PPO provider listTimmes would use the confirmatory consult codes instead of the office visit codes.

Tip: Confirmatory consult codes are also appropriate when an insurance company requests a second opinion.

CPT indicates that the physician should use the 99271-99275 codes when he or she is aware of the confirmatory nature of the service being rendered. Of course, this can only be accomplished if the patient reveals he or she has already been to a specialist and is now seeking a second opinion.
The majority of Timmes patients belong to PPOs. Often, the originating physicians of such patients dont transmit a written request for consultation (they ask him on the telephone), nor does the patient bring along a written request. This automatically reduces the number of outpatient consultations (99241-99245) the retinologist does, since in order to bill and receive payment for these services, Timmes must be provided with a report by the requesting physician.

Request Precise Referral Forms

If you can manage this stephaving the initial physician fill out the referral form accuratelymany of your consultation reimbursement problems will be solved, says Kaiden. Its a big problem when the sending doctor doesnt know what to put on the form, she says. Its rarely filled out the right waythe originating doctors are frequently in a hurry. For example, lets say a patient comes to you to have visual fields done. If the originating physicianmost likely the patients primary care provider doesnt specify on the referral form that he is authorizing tests and procedures to be done, you cant get paid for those services as a consult, says Kaiden. One option is to call the physician to get the correct form faxed to you. But then that initial doctor may get mad because youve interrupted him, notes Kaiden. If he gets mad enough, he wont send you any more referrals, and we base our practice on referrals. The other option is to tell the patient to go back to the first physician to get the correct form. In this scenario, the patient starts to hate the original doctor and the ophthalmologist, the ophthalmologist hates the first doctor and vice versa, Kaiden says in disgust. The solution is to have a good working relationship with the doctors who requests your ophthalmologists opinion. Talk about the problem the first time it happens; this will help ensure that it doesnt happen again.

Review Your Contracts

One dilemma with consultations is preoperative visits, says Dari Bonner, CPC, CPC-H, CCS-P, coding reimbursement specialist for Martin Memorial Health Systems in Port St. Lucie, FL. Were getting a lot of denials on consultations for pre-ops, says Bonner, who codes for 10 ophthalmologists. I think it may be a contract issue, she says.

In many cases, HMOs apply the concept of a specialist to a consultation code, says Bonner. I think they may want people to use ophthalmology codes [92002, 92004, 92012, 92014]. The eye codes dont pay nearly as well as the consultation codes.

You have to review your contracts carefully, says Bonner. If the contract tells you to use the eye codes instead of consult codes, youre forced to do so, even if its not correct coding. Each year when your contract comes up for renewal, look at it carefully and make any changes that are necessarysuch as making sure you are allowed to bill for a consultation the first time you see a patient, if you are assessing the need for surgery for another physician. You can always negotiate, the coding reimbursement expert states.

Its a good idea to make sure your contracts spell out coding policy, Bonner says. Ironically, from a compliance standpoint, we are liable, she says. If Medicare tells us to do something incorrectly, were liable unless we get it in writing that that is what we were told to do, she says. And its the same with other carriers. Thus, if the incorrect coding is required in the contract (in writing), you are no longer liable.

HMO Pressure to Use 92002

This is a sore point, because at least one large HMO is trying to force ophthalmologists to use strictly eye codes, instead of consultation codes. The HMO is doing this by putting CPT code to read 92002 (ophthalmological services, intermediate, new patient) on the bottom of its referral (request) forms. Our doctor called them and said, How do you know what we did?, says Kaiden. Theyre trying to trick us into using a cheap code, she opines. Kaiden followed up her physicians inquiry with a call to the provider relations representative, asking, Were you in the room with the doctor? Do you know what he did? This HMOs request form currently has three choices, says Kaiden: office visit only, consultation with report, and consultation with diagnostic studies and report. We do a report, and its a consultation, she says. So why do they tell us to use 92002?

The only way to handle such situations, Kaiden stresses, is to fight. When any of our coding is challenged in an EOB, we go to war, she says.

If you are asked to evaluate a patient and report back to the first doctor, you are being asked to consult, says Kaiden. If thats what were doing, thats what it is, and thats what were going to charge, she says. Were being asked to consult, the request form says consultation, and thats how were coding it.

Editors Note: While we have been talking about using consultation codes for new patients, we want to remind readers that you can also use a consultation code for an established patient. For example, an established patient of yours might be sent to you by his or her primary care physician for evaluation due to headaches. If you are asked to consult and report back to the primary physician, you should use a consultation code, even though you have seen the patient previously.

Various Consult Codes 99241: office or other outpatient consultation for a new or established patient (problem-focused history, problem-focused exam, and straightforward medical decision-making) 99242: office or other outpatient consultation for a new or established patient (expanded problem-focused history, expanded problem-focused exam, and straightforward medical decision-making) 99243: office or other outpatient consultation for a new or established patient (detailed history, detailed exam, and medical decision-making of low complexity) 99244: office or other outpatient consultation for a new or established patient (comprehensive history, comprehensive exam, and medical decision-making of moderate complexity) 99245: office or other outpatient consultation for a new or established patient (comprehensive history, comprehensive exam, and medical decision-making of high complexity) 99251-99255: initial inpatient consultation codes. 99261-99263: follow-up inpatient consultation codes. 99271-99275: confirmatory consultation codes.