Ophthalmology and Optometry Coding Alert

It’s time to go retro when you’re reporting these services.

Whether your ophthalmologist is seeing inpatients for detached retinas, corneal ulcers, orbital fractures, or other serious situations, you’ve got to understand how to code hospital visits. Although the changes surrounding the revised office/outpatient evaluation and management (E/M) codes seemed all-consuming last year, those changes apply only to office and outpatient E/M services; they do not affect how you report the inpatient E/M codes.

To ensure you’re reporting your inpatient services properly, check out this quick rundown of hospital coding.

Use These Codes for Initial Day

When reporting your ophthalmologist’s initial day of hospital care, you’ll choose from one of the following codes depending on encounter specifics:

• 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. …)
• 99222 (… A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. …)
• 99223 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. …)

Important: Remember that you need to satisfy all three components for these codes — history, examination, and medical decision making (MDM) — unlike office/ outpatient E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.), which had their descriptors altered radically for 2021.

As for whether you count all E/M services that day toward the overall code level, the answer is: it depends.

All E/M services by the same specialty and same provider should be combined during that initial 24-hour period. If the ophthalmologist admitted the patient and then needed to see the patient later in the day, the information should be added together in support of one visit code with the AI modifier (Principal physician of record) appended. This denotes the ophthalmologist as the admitting doctor. If a different specialist sees the patient, that service could also be reported with a 99221-99223 code selection. The AI modifier would not be appropriate as that specialist wouldn’t be the admitting physician.

Be sure to include the correct documentation to solidify the claim, including the documentation of all providers under the same specialty on the same calendar day: medical doctors (MDs), doctors of osteopathic medicine (DOs), physician assistants (PAs), nurse practitioners (NPs), etc. This would require notes that these providers actually wrote. It would not include hospital staff documentation, as that information would be considered when charging and coding the hospital services themselves.

Use Separate Code Set for Subsequent Care

When coding for subsequent hospital inpatient services, choose from one of the following codes, depending on encounter specifics:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. …)
• 99232 (… An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. …)
• 99233 (… A detailed interval history; A detailed examination; Medical decision making of high complexity. …)

Documentation is also key to choosing the correct subsequent hospital care code. If only one provider sees the patient, that provider’s note is used to determine the appropriate level of service. If additional providers of the same service/same specialty see the patient, include their information with your provider’s documentation when determining the most accurate code.

30-Minute Mark Crucial for Discharge Code Choice

When the provider discharges the patient, you’ll choose from one of the following codes, depending on encounter specifics:

• 99238 (Hospital discharge day management; 30 minutes or less)
• 99239 (… more than 30 minutes)

These codes include:

• the final evaluation of the patient;
• summary of the hospital visits (including final diagnosis/es);
• the treatment plan; and
• the follow-up plan.

Documentation alert: The documentation should include the final exam elements as well as the information around the discharge — i.e. education, meds, follow-up, course of care, etc. — along with the time spent in the activity of the discharge.

Example: Suppose your ophthalmologist sees a patient who has been admitted from the emergency room for a vitreous hemorrhage and ocular injures following trauma affecting the right eye. The ophthalmologist is not the admitting physician, but sees the patient the day after admission and performs an expanded problem focused exam, an expanded problem focused interval history, and medical decision making of moderate complexity. In this case, you’ll report 99232.

The admitting physician performed and billed for the initial hospital care on the first day of the patient’s stay, so your provider will only report subsequent hospital care codes from the 99231-99233 range prior to the patient being discharged. The diagnosis for the ophthalmologist’s visit will include H43.11 (Vitreous hemorrhage, right eye).