Ophthalmology and Optometry Coding Alert

Ophthalmologists are sometimes called to the hospital emergency department (ED) to see a patient with eye pain. What is the best way to code for this encounter?

That depends on whether another physician has already seen the patient. Paula Lander, insurance and coding clerk for Drs. Taylor and Winslow of Dallas, TX, uses the ED services codes (99281-99285), because the ophthalmologist is the only doctor who examines these patients.

Shirley Bacon, who does the postings for Drs. Jones and Aul of Edmonds, WA, uses the outpatient consultation codes (99241-99245) for these encounters. Thats because the ED physician is already using the ED codes, she says. If the patient is in the emergency room, we assume that another doctor has seen him or her first, she says. So we do this as a consultation and use the ED physician as the referring doctor.

According to Bacon, it's best to send a letter to the ED physician detailing your findings. But, the biller says, the ED situation usually occurs with both physicians there, and the ophthalmologist can discuss what he or she has found during the consultation.

Diagnosis Codes are Key to Reimbursement

In the emergency room, we regularly see corneal abrasions, corneal ulcers, and corneal lacerations, says Lander. So we have these diagnoses on our list when the ophthalmologist goes to the hospital.

What if the ophthalmologist doesnt find any of these? Most of the time, we have to eat that cost, says Lander, laughing ruefully. Would a diagnosis of eye pain (379.91) be enough to get reimbursed? Sometimes, says Lander. It would depend on the level of the E/M code.

Asked how her office handles eye pain as a diagnosis, Bacon admits that this can be a major problem. If it turns out theres nothing wrong, then you have to write letters to the insurance company, says Bacon. The letter should detail the scenario of what occurred: that the patient went to the ED with trauma, that the ED physician didn't feel it was within his or her scope of practice and called in the ophthalmologist, and then the fact that the ophthalmologist found only signs and symptoms. It's important that you at least code signs and symptoms, which the patient presented with, even if you have no more definitive diagnosis, says Bacon.

It works some of the time. She never just writes off the fee, however. The patient is billed if the insurance company wont pay.


ED Patients Without Insurance

A bigger problem for Lander, however, is that most patients who go to the emergency room for eye pain dont have any insurance. And most of the time, she is unable to collect the payment from them. If we see a patient in the emergency room on a Saturday night, we tell them on discharge they should come to the office on Monday or Tuesday, says Lander. If they show up for that appointment, she can almost always work out a payment plan. But most of these patients dont even show up for the follow-up. She cited one case of a patient who was injured at worka carpet layer who got a staple in his eye. Since this was work related, workers compensation should have covered the ophthalmologists bill. When Lander called the employer, however, she was told that the carpet layer was not an employee, but an independent contractor who had his own insurance. Thats one of the costs of having surgery privileges in a hospital, says Lander.