Ophthalmology and Optometry Coding Alert

Question: A patient presented at our office worried that she had a detached retina due to “seeing spots.” She also had a large bruise around her eye and said she didn’t know how it happened. She displayed other behavior as well that led the physician to think perhaps it was a domestic abuse situation. The ophthalmologist examined the patient and determined she did not have a detached retina or other ophthalmological problems, but suspected she may have had a concussion so he sent her immediately to the local hospital’s emergency department. How do we bill the office visit code? Also, which diagnosis should we report for suspected domestic abuse?

Alabama Subscriber

Answer: The answer to your first question is determined by where the physician saw the patient. Since your physician only saw the patient at your office, then you should bill a standard office visit code (99201-99215, Office or other outpatient visit for the evaluation and management …). If the service was in the office and the patient had testing and treatment, you may also be able to report an eye code from the 92002-92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program …) range.

However, if the doctor had gone to the hospital to see the patient as an inpatient the same day as an earlier office visit, you would report the appropriate hospital visit code from the 99221-99233 range instead. If you go this route, you won’t bill the office visit — instead you will roll the physician’s work at the office into the appropriate hospital inpatient visit code.

As for the diagnosis code, you can report suspected abuse using T76.11XA (Adult physical abuse, suspected, initial encounter). CPT^® indicates that the provider should also code any injuries, such as the bruising (S00.11XA, Contusion of right eyelid and periocular area, initial encounter; S0012XA, … left …; S00.10XA, … unspecified …), and the fact that the patient was seeing spots (H53.8, Other visual disturbances).