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).
Medicare Pays Less for ED Visits
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.
ED Coding: What You Can Bill
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 [...]
