Ophthalmology and Optometry Coding Alert

A common question in ophthalmology is: How do you receive additional reimbursement for the time spent with a patient and their family to discuss surgery options? These visits can be time-consuming, and there isnt necessarily any justification for using a level five code. One answer is to use the prolonged services codes in addition to the appropriate E/M services code, says Terry Fletcher, CPC, CCS, a coding seminar leader for McVey Associates. The prolonged services codes (99354-99355) are for face-to-face contact with the patient or family, on an outpatient basis.

The time does not have to be continuous, says Fletcher; it is total time on a given date. So if the physician spends this time at the exam encounter, sends the patient to the testing room and the patient returns the same day to go over results with the physician, the clock continues to tick when defining prolonged services, Fletcher notes.

Lets say a new patient comes in for a cataract evaluation. You bill 99204 for a new patient examination (making sure you meet the requirements for the exam elements for a fourth-level visit). Then, in addition to the exam, you spend 35 minutes counseling the patient and her husband. You should also code 99354 (prolonged physician service in the office or other outpatient setting, first hour), which will cover your counseling time.

Prolonged services are usually reimbursed at about $87 to $106 in addition to the visit, says Fletcher. But you must document the time.

Tip: The prolonged services codes are piggyback codes. To use these codes, you must bill them with an E/M services code. Many payers, Medicare included, say that you should first code for the maximum time allowed for the E/M code, and then add the prolonged services code as appropriate.

Note: If more than 50 percent of the time is spent in discussing surgery options, then you can use time to choose a level of E/M service. For example, if you spend 20 minutes counseling on surgery options, and 20 minutes examining the patient, you could use an E/M services code level 5 -- which requires 40 minutes. Most payers interpret prolonged services as meaning that first you need to max out the appropriate level of care. So if, taking the above example, you spent more than 21 minutes counseling, then you could add on a prolonged services code.