Ophthalmology and Optometry Coding Alert

When one ophthalmologist is on call for another from a different group, what is the best way to do the billing? We have spoken to practices who dont bill this at all, but just do it on a quid-pro-quo arrangement, with each practice covering for the other at various times. And we dont recommend thisit leaves each doctor open to financial liability. One ophthalmologist might end up with a very time-consuming patient to deal with, perhaps one who just had surgery, fitting this patient in his or her regular schedule. Assuming that the inequities will all balance out in the end just doesnt work. Of course, it does save paperwork. But we recommend actually billing for the work you do on call. Heres how two practices we talked to do it.

1. Use new patient codes. If you have never seen the patient before (or havent seen the patient within the past three years), use the new-patient E/M services codes (99201-99205 for outpatient; the inpatient codes are the same for new and established patients: 99221-99223) or the new-patient eye codes (92002, 92004). This is how Suzanne Grant, office manager for O. Duane Ragland, MD, a five-ophthalmologist practice in Clinton, MD, bills for coverage of another practice. We bill just as if the doctor were seeing his own patient, says Grant. If hes never seen the patient before, we bill a new-patient code, even if were covering for another doctor. Linda Greene, insurance clerk for Danville Eye Center, a one-ophthalmologist, one-optometrist practice in Danville, VA, agrees. If weve never seen the patient, its a new patient.

2. Post-surgery patients. In the only exception to the above, Greene does not bill at all for patients who are coming in during the post-surgery global period. We dont charge in those cases, the insurance clerk reports. According to Lise Roberts, vice president of Healthcare Compliance Strategies in Syosset, NY, you should handle the billing as if you were the surgeon who billed the whole global surgical package.

For example, a normal post-op check-up or follow-up of a complication, that didnt require returning the patient to an operating room, would not be billed because those services are part of the global surgical package, Roberts explains. But if the patient has a problem unrelated to the surgery, the surgeon would bill the services with the -24 or -79 modifier attached. The ophthalmologist who is covering for the surgeon should handle the billing the same way, says Roberts. Of course, the diagnosis or diagnoses submitted must reflect an unrelated condition or the modifier for the un-operated eye as the medical necessity for the additional billed service or services.

Note: The -24 modifier would be attached to an E/M code or an eye examination code, whereas the -79 modifier would be used for a procedure performed which was unrelated to the original surgery and didnt require returning the patient to an operating room, Roberts explains. This most often would be a minor surgical procedure to correct a problem such as a chalazion or trichiasis.

3. Reporting back. There is a price to pay for covering for another practice. You cant get reimbursed for the extra work involvedand there is extra work. We always send a letter back to the patients doctor, says Grant. But its worth it. The other practice covers for us when we need it.