Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist is sometimes called to the hospital emergency department to see a patient and has to admit that patient. Sometimes the patient comes directly to our office with an emergency and must be admitted. How do we decide whether to bill a hospital admission or an office visit?

Ohio Subscriber

Answer: You cannot bill more than one evaluation and management (E/M) service for that day of the emergency. To maximize your reimbursement and avoid fraud, you need to pick with care the one E/M service you will be allowed for that day. Wherever the initial encounter takes place, if the ophthalmologist must then admit the patient to the hospital, a choice must be made about what E/M service to bill.

Following are the scenarios of a patient seen under different circumstances, and the correct codes to use:

1. The patient is seen in the ophthalmologists office and admitted to the hospital: Add the office visit work to the hospital admission work, and use the hospital admission code that represents all the visit work that day. The correct way to bill for the care rendered in the office and the initial admission hospital care is to charge for the initial inpatient admission and include the history, exam and medical decision-making performed in the office. So you would pick the most appropriate level of the hospital admission codes (99221-99223). You cannot bill for an office visit and a hospital admission, even with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Even if you see the patient in your office twice once in the morning, and then again in the afternoon when the condition has worsened before doing the admission, you will bill only the hospital admission code. Code 99223 would be the most appropriate admission code because you are adding an already intensive office visit (probably a 99214 or 99215) to the hospital admission, which in itself is likely to merit a high-level code.

2. The patient is seen in the emergency room and admitted to the hospital: Again, you would select the hospital admission code that includes the work done in the emergency room, providing that the ophthalmologist is the one admitting the patient. If the emergency room physician admits the patient, and calls the ophthalmologist in for a consultation while the patient is in the emergency room, code a consultation (99241-99245) for that visit. However, you would not be able to bill for a hospital visit on the floor that day. You can bill for a consultation and treat the patient for the problem as well. Just remember to document the request for the consultation and to write a report for the requester (the emergency department physician in this case).

Its not automatically a consultation when the ophthalmologist is called in to the emergency department. You can bill for a consultation and treat the patient as well, but not if the emergency room physician transfers care to you then and there. For example, if you go to the emergency room because the physician says theres a splinter in a patients eye, and you have to take it out, thats not a consultation. This is a fine line.

3. Emergency codes: You may have noticed that in a high-intensity case such as this that coding globally doesnt make that much difference in terms of reimbursement. You may have been justified in coding the hospital admission a 99223 even if you hadnt seen the patient in the office earlier in the day, yet using one 99223 is the most you can code. There is also an emergency code 99058 (office services provided on an emergency basis). Medicare doesnt pay for 99058, but some private payers do. If you want to use 99058, you should get it into the contract with the payer during negotiations.


Answers to You Be the Coder and Reader Questions contributed by Lise Roberts, vice president, Health Care Compliance Strategies, fraud awareness and billing consultant, Jericho, N.Y.; Raequell Duran, president, Practice Solutions, ophthalmology coding and compliance consultant, Santa Barbara, Calif.; Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc., a coding and compliance consulting firm based in Spring Lake, N.J.; and Vicki Davis, COA, lead technician, Cascade Eye Center, The Dalles, Ore.