Ophthalmology and Optometry Coding Alert

When a patient is going through a narrow angle attack (365.22) or an angle closure attack (365.20), the work of the ophthalmologist can be difficult and time-consuming. But the ophthalmologist can be paid for that work, providing he or she documents well.

Glaucoma (365.xx) occurs when aqueous (water-like) fluid has difficulty passing through the area where the iris and cornea come together (the trabecular meshwork). During a narrow angle or angle closure attack the area becomes completely blocked, and pressure can build up quickly. Usually, the eye is quite painful. There even may be nausea and vomiting. These are emergency situations, but can be treated in the office. Nevertheless, the patient may be in the office for hours.

Jon Winders, clinic coordinator for Umpqua Valley Eye Associates in Roseburg, Ore., describes two very similar scenarios, one in which he was able to optimally code and the other in which he could only code minimally with the difference due entirely to documentation.

Scenario 1: The first scenario took up most of the ophthalmologists day, but resulted in an inability to bill more than a fifth-level office visit due to lack of documentation. The woman had an anatomically narrow angle (365.22), says Winders. Sooner or later, we knew she would have an attack. The doctor advised her to have a laser procedure 66761 (iridotomy/iridectomy by laser surgery [e.g., for glaucoma] [one or more sessions]) but she declined due to a planned trip. A few days later, she got a narrow angle attack. She was very sick, Winders recalls. She was vomiting and in a lot of pain.

The patient was in the ophthalmologists office all day. In addition to having glaucoma, the patient was a diabetic (250.x) and risked further problems because she couldnt keep any food down. The ophthalmologist gave her an antiemetic to help with the vomiting, but was not able to do the laser surgery. By the end of the day, the ophthalmologist called the patients primary-care physician (PCP), who admitted the patient to the hospital using the diabetes diagnosis. If the ophthalmologist had admitted the patient, the only charge the ophthalmologist would have been able to use for the entire day would have been a hospital admission code (probably a 99223). As it turned out, the ophthalmologist could bill a 99215 (office or other outpatient visit for the evaluation and management of an established patient). The ophthalmologist failed to document the time he spent with the patient and all the services he performed for the patient.

Winders could not bill 99058 (office services provided on an emergency basis) or 99358 (prolonged evaluation and management service . . . first hour) and 99359 (each additional 30 minutes). We could have used emergency services or prolonged services, but I didnt feel the case was documented well enough, says Winders.

Scenario 2: In the other case, Winders was able to bill emergency and prolonged services, as well as after-hours services, because it was documented thoroughly. In this case a one-eyed patient with very high pressure went to the emergency room early on a Saturday morning with an angle closure attack. The emergency room called the ophthalmologist, who met the patient at the ophthalmologists office. He spent pretty much all day with him, notes Winders. He dictated absolutely everything he did. Time was tracked by a time-in, time-out method. For example, when the ophthalmologist came into the room he documented the time, when he left he wrote down the time, when he returned he wrote down the time, etc. At the end of the day he added up all the time spent in the room with the patient. This doctor is very thorough in documenting, notes Winders. I felt this visit was documented so well that I billed it to the max. This included 99215, 99058, 99358, 99359 and 99050 (services requested after office hours in addition to basic service).

Medicare immediately asked for chart notes. I thought, good. I sent them in, and we got paid, recalls Winders.

Many ophthalmologists feel that spending a lot of time on documentation is too complicated and time-consuming. They look at it from a productivity standpoint, too, because it is costly to type, says Winders. But the glaucoma scenario is a case in point. Winders now has a scribe for every doctor except for the one who dictates well.