Ophthalmology and Optometry Coding Alert

Question: How should I code an office visit for a wheelchair-bound nursing home patient who comes in for a follow-up for glaucoma? Texas Subscriber Answer: Ophthalmologists often have to follow up with glaucoma patients because of medications or postsurgical concerns. Many practices differ in their coding method for follow-up visits, using either E/M (99201-99215) or eye codes (92002-92014). Both sets are acceptable as long as they accurately depict the service. The decision usually depends on the physician's preference. However, the ophthalmologist must perform the required elements of the code selected, and he must consider those elements medically necessary for the patient's presenting problem, to bill the appropriate eye code or E/M code level. In documenting follow-up glaucoma visits, be sure always to document a chief complaint even if it is simply "follow-up glaucoma." Hidden trap: Billing can be complicated if the nursing home resident is a skilled nursing facility (SNF) [...]