Ophthalmology and Optometry Coding Alert

Question: I think my physicians frequently perform office visits that warrant coding at level four or higher, but I-m concerned about raising red flags for upcoding. How can I determine when I-m justified in billing a  level-four service?


Tennessee Subscriber

Answer: Your first step in choosing the correct code is looking at the differences in the code descriptors for 99213 and 99214:

- 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

- 99214 -- - a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

To report 99214, your physician must document at least two of the following: a detailed history, a detailed exam, and medical decision-making (MDM) of moderate complexity.

Important: You also need to be sure that the nature of the presenting problem and medical necessity support coding a level four. Many coding consultants recommend not selecting an established patient E/M code level above that supported by the MDM level.  

Caution: Automated systems set up to document every possible piece of history and examination for every patient will certainly attract auditors- attention, particularly if the history and exam are at the high end of documentation but MDM is low or straightforward.

Potential problem: Some insurers put up red flags when a practice only reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that level.

Bottom line: Choose your E/M code based on the physician's documentation every time, and your coding will naturally reflect the physician's range of services. The three most common instances that warrant reporting 99214 are:

- An established patient presents with a new problem to the examining physician

- An established patient presents with one chronic (ongoing) or worsening problem and one stable problem

- An established patient presents with three stable chronic or inactive problems/illnesses.

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, in Clearwater, Fla.