Ophthalmology and Optometry Coding Alert

Many ophthalmologists wonder what kind of a case would justify a 99205 or 99215. Some coders tell us they never code a level five evaluation and management (E/M) service. But even the Health Care Financing Administration (HCFA) has an expectation that there will be some level fives out there otherwise, the codes would not exist. Is ophthalmology really so prohibited from the cases that justify a level five?

If we have a choice between a level five and a 92014, well use the 92014, says Evan Malloy, business coordinator for The Eye Center of Menomonee Falls, Wis. We usually use the eye codes instead of the E/M service codes anyway, he says. The exception is pre-op cataract surgery multisystem medical evaluations. The practice often uses level-four E/M codes for these visits, says Malloy.

Melodie Aeder, COE, network manager for Andersen Eye Associates of Saginaw, Mich., agrees that there are many pre-op cataract visits that require a level four. I think thats pretty standard, she says. If its a new cataract, or if an existing cataract has changed, and if there are physical problems also examined, we would code a level four, she says. If, however, the patient returns four months later wanting to have the other eye operated on, it would be best not to bill a level four for that visit unless there are new medical conditions or problems with the existing conditions, says Aeder.

Unlike Malloy, Aeder bills level five visits, but very rarely. Our retina doctors might use a level five, but only under certain conditions, she says. Lets say the patient has glaucoma, and other eye problems. On top of that, the patient had a stroke, a heart operation, or is on oxygen. And the patient comes in with a retinal detachment. This encounter is clearly a level five visit, says Aeder. But we dont see a lot of it, she says. Two level-five visits per subspecialist a month is about the maximum, the coder tells us.

The key to a level-five visit is not only the eye problems, but other physical problems that could complicate the treatment of the patients problem, says Aeder.

Remember that if you do use the level-five E/M codes excessively you may place yourself at a higher risk for an audit of those services, notes Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and compliance consulting firm specializing in ophthalmology. Aside from the mandatory, pre-payment audits of the E/M codes that the carriers must perform, carriers can also create what are called screens in their computer systems, explains Duran. New patient category level-five visits and this includes consultations require documentation of comprehensive history, comprehensive examination and medical decision-making of high risk. Since carriers know that this type of visit is less common, says Duran, they may set up a screen to deny the services for medical necessity so that you will have to submit a copy of the chart documentation prior to payment. Some practices set up an automatic, internal audit of visits that are coded at level-five to ensure the chart documentation is up to snuff prior to billing.