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Ophthalmology and Optometry Coding Alert

Optimal Coding for Exams Performed in Nursing Homes

Published on Tue Jun 01, 1999

I have free time on weekends and would like to do ophthalmological exams in some local nursing homes, writes J. Daniel Carpenter, MD, an ophthalmologist in Cranberry Township, PA. What would be the proper and maximal way to code for doing exams in a nursing home?

For an answer, we talked to Nicole Marshall, billing manager for Scott and Christie and Associates, a two-ophthalmologist, one-optometrist practice in Pittsburgh, PA. For most of the nursing homes the doctors go to, Marshall uses 99261, 99262, or 99263the follow-up inpatient consultation codes. There are a lot of primary care providers in the area who ask us to go to nursing homes to see their patients, says Marshall.

These follow-up inpatient consultation codes actually have two uses: (1) to complete the initial consultation, or (2) subsequent consultations requested by the attending physician. But the key is that there must be an attending physician who is requesting the consultation, and the ophthalmologist must report to this attending physician. Usually we leave a report in the patients chart, says Marshall.

The follow-up inpatient consultation codes include monitoring progress, recommending management modifications, or advising of a new plan of care in response to changes in the patients status, according to CPT. These codes are for follow-up consults provided to either hospital inpatients or to nursing home residents. (See box in next column for follow-up inpatient consultation codes.)

Note that you can also use the initial inpatient consultation codes (99251, 99252, 99253, 99254, and 99255) the first time you see a patient in the nursing home. These codes are for use whether the patient is new or established, but you may only use an initial consultation code once per admission. Also, like the follow-up inpatient consultation codes, these codes are for hospital inpatients as well as for residents of nursing facilities. (See box in next column for initial inpatient consultation codes.) Once again, the key is that you must have a request from another provider for the consultation, and you must make a report to that provider.

Clinic-Type Situations

Sometimes, however, its hard to find an attending physician. This is the case with an institution which Marshalls ophthalmologists go to once a month. The facility used to be a nursing home, but now has many different kinds of patients, many of whom are severely mentally disturbed. There isnt an attending physician, so were not using the inpatient consultation codes for these visits, says Marshall. Instead, were using 99311, 99312, and 99313. These codes are for subsequent nursing facility care. (For a list of codes and their definitions, see box on this page.) These codes are specifically for residents of nursing facilities. All codes are reported on a per-day basis.

The doctor scrolled through CPT and thought these codes (99311, 99312, and 99313) would be more accurate than the consultation codes, since theres no referring physician, says Marshall. Sometimes these patients do have a problem that requires surgery; one patient needed cataract surgery, and Marshalls office did the A-scans and the procedure on the same day. But in general, the patients are just seen briefly.

The doctor just goes to the center every month, and sees a list of about 10 patients, she reports. Half of the patients cant even speak. The center gives the practice the names, insurance information, and social security numbers of the patientstheir addresses are the institution. Then the practice makes up the charts and the ophthalmologist sees the patient. Medicare pays us $48 on a 99312 and $66 on a 99313, which is what most of these visits are, says Marshall. And we havent had any problems with using these codes.

Coding for Nursing Home Exams

1. Follow-up Inpatient Consultations:
99261: A follow-up inpatient consultation requiring at least two of the following: (1) a problem-focused interval history, (2) a problem-focused examination, and (3) medical decision-making that is straightforward or of low complexity. The patient is typically stable, recovering, or improving. The ophthalmologist would spend 10 minutes at the bedside and on the patients floor or unit.

99262: A follow-up inpatient consultation requiring at least two of the following: (1) an expanded problem-focused interval history, (2) an expanded problem-focused examination, and (3) medical decision-making of moderate complexity. The patient is responding inadequately or has developed a minor complication. The ophthalmologist would typically spend 20 minutes at the bedside and on the patients floor or unit.

99263: A follow-up inpatient consultant requiring at least two of the following: (1) a detailed interval history, (2) a detailed examination, and (3) medical decision-making of high complexity. The patient is usually unstable or has developed a significant new problem or complication. The ophthalmologist would typically spend 30 minutes at the bedside and on the patients floor or unit.

2. Subsequent Nursing Facility Care:
99311: Nursing facility care for a new or established patient which requires as least two of the following: (1) a problem-focused interval history, (2) a problem-focused examination, and (3) medical decision-making that is straightforward or of low complexity. The patient is stable or improving, and physicians typically spend 15 minutes at the bedside and on the floor.

99312: Nursing facility care for a new or established patient requiring at least two of the following: (1) an expanded problem-focused interval history, (2) an expanded problem-focused examination, and (3) medical decision-making of moderate complexity. The patient is responding inadequately or has a minor complication. Typical time spent at the bedside and on the floor is 25 minutes.

99313: Subsequent nursing facility care for a new or established patient requiring at least two of the following: (1) detailed interval history, (2) detailed examination, and (3) medical decision-making of moderate to high complexity. Usually there is a significant complication or new problem. Typical time spent at the bedside and on the floor is 35 minutes.

3. Initial Inpatient Consultations:
99251: An initial inpatient consultation for a new or established patient requiring the following: problem-focused history, problem-focused examination, and straightforward medical decision-making. The presenting problems are usually minor. The typical time spent at the bedside and on the floor is 20 minutes.

99252: An initial inpatient consultation for a new or established patient requiring the following: expanded problem-focused history, expanded problem-focused examination, and straightforward medical decision-making. Problems are of low severity, and typical time spent at the bedside and on the floor is 40 minutes.

99253: An initial inpatient consultation for a new or established patient requiring the following: detailed history, detailed examination, and medical decision-making of low complexity. The problems are usually of moderate severity; typical time spent at the bedside and on the floor is 55 minutes.

99254: An initial inpatient consultation for a new or established patient requiring the following: comprehensive history, comprehensive examination, and medical decision-making of moderate complexity. Problems are of moderate to high severity, and the ophthalmologist would typically spend 80 minutes at the bedside and on the floor.

99255: An initial inpatient consultation for a new or established patient requiring the following: comprehensive history, comprehensive examination, and medical decision-making of high complexity. Problems are of moderate to high severity, and typical time spent at the bedside and on the floor is 110 mminutes.


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