Ophthalmology and Optometry Coding Alert

Coding for traumatic eye injuries depends on whether the ophthalmologist provides treatment in the emergency department (ED) or in the office. Although traumatic eye injuries sometimes require additional time and skill, Medicare will not pay extra when the ophthalmologist performs an emergency procedure or treats the problem outside of office hours. However, some commercial payers recognize the emergency office code (99058) and the after-hours codes (99050-99054).     

 
Treating patients in the ED pays ophthalmologists less then treating them in the office when the payer is Medicare, says Raequell Duran, president of Practice Solutions, an ophthalmology coding consultancy based in Santa Barbara, Calif. "That's because of the distinction between services performed in a facility setting versus a nonfacility setting," she says. When you perform a service in the office, it's considered a nonfacility service because an additional fee for a facility charge will not be submitted to Medicare. The physician receives more reimbursement because the payment is for the practice expense as well as his or her time. If, on the other hand, the ophthalmologist provides the service in an ambulatory surgery center (ASC) or in the ED, he or she is paid less. The hospital will bill a fee for the room, and the physician will get a reduction. The reduction represents 50 percent of the practice expense assigned. This translates into about a
20 percent reduction overall.
 
For example, in northern California, the Medicare fee schedule pays $90.35 for 99242 (office consultation for a new or established patient ...) provided in the office. Provided in a facility, such as an ED, 99242 pays only $70.87. Code 99243 pays $119.51 in the office, compared to $94.47 in a facility.
 
If the payer is a commercial insurance company, HMO or PPO (not Medicare), there typically is no site reduction for going to the ED.

 
When the ED physician charges for the emergency visit, the ophthalmologist cannot bill. But if the ED physician calls the ophthalmologist for a consultation, the ophthalmologist can bill 99241-99245. "Some carriers will pay for this visit as a consultation. Some prefer that you bill a new outpatient visit (99201-99205) instead," says Margaret Mac, CPC, CMM, a coding consultant based in Tampa, Fla. "You need to meet all the requirements for a consultation." This includes a documented request for your opinion from the ED physician.
 
"If what is happening is merely a transfer of care -- the ED doctor does not examine the patient and hands the patient to you for treatment -- you can't bill a consultation," Mac says. You would have to code either an ED visit or an office or other outpatient visit.
 
You cannot bill an emergency-department code (99281-99285) unless the problem is a true emergency and you are the only physician billing an ED visit. If the problem did not constitute a true emergency (usually defined as the threat of loss of life or the permanent loss of the use of an organ or limb if not treated on an emergency basis) or if the ED physician examines the patient before calling you in (so he or she will be using an ED code), you cannot use an ED code. In these cases, you would use an office or other outpatient visit code (99201-99215) or an eye code (92002-92014).

 
If you bill for providing an emergency service in the office, use 99058 (office services provided on an emergency basis).
 
The following are common traumatic eye injuries that the ophthalmologist performs.
 
1. Foreign body in eye. If a patient was mowing the lawn (without adequate eye protection) and debris flew up in his or her face, the physician must remove a foreign body from the eye.
 
Code selection depends on the location of the foreign body. The most common removal codes used by ophthalmologists are 65205*-65222*. All starred procedures, these can be billed with sick visit E/M codes (99201-99215), eye exam codes (92002-92014) or with consultation codes (99241-99245) depending on the circumstances.  
 
In some cases, a laceration must be repaired after removal of a corneal foreign body. If you perform a laceration repair, use 65275 (repair of laceration; cornea, nonperforating, with or without removal foreign body). You cannot use a code for foreign-body removal in addition, as the removal is bundled into the repair by CPT.
 
When the foreign body is in the eyelid, use 67938 (removal of embedded foreign body, eyelid). CPT says this procedure is blepharoplasty and must involve more than the skin. Code 67938 must involve the lid margin, tarsus and/or palpebral conjunctiva.
 
2. Burns. Burns from sparklers are usually treated with an antibiotic and a patch. Bill an office visit. There is no code for the patch. Use the diagnosis that reflects the area burned (940.x). If the burn extends beyond a specific area of the eye, use 941.xx, with the fifth digit .x2 indicating the eye. 
 
3. Blows. A blow to the eye would probably call for a dilated exam and perhaps even extended ophthalmoscopy (92225), depending on the extent of the injury. Code an eye exam (92002-92014) or an E/M visit (99201-99215).
 
4. Hemorrhage. Some injuries look worse than they are to the patient, such as a subconjunctival hemorrhage. A blood vessel bursts and the white of the eye turns red; treatment is minimal, however. The emergency department might not even send the patient to you. But if the patient goes directly to your office, use 992xx and diagnosis code 372.72.

Using the After-Hours Codes

 
Sometimes for emergencies, ophthalmologists work past their regular office hours. There are different after-hours codes depending on when the service is provided. Use 99050 (services requested after office hours in addition to basic service) when services are requested "after office hours." Use 99052 (services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) when services are requested between 10:00 p.m. and 8:00 a.m., and use 99054 (services requested on Sundays and holidays in addition to basic service) when services are requested on a Sunday or holiday.
 
Technically, these codes can be billed together. But even commercial payers that recognize them are not likely to reimburse for more than one after-hours code. If you see a patient for an emergency in the office at midnight and the payer is a private HMO, you may be able to bill 99215 and 99052, but you will probably not be able to bill 99050 also. If the payer is Medicare, you will receive nothing for those codes.