Ophthalmology and Optometry Coding Alert

Question: We saw a patient from another practice whose insurer requested a second opinion to approve strabismus surgery. The patient was evaluated, and the ophthalmologist concurred that the procedure was necessary. Should I code this service differently from consult requests from other doctors?

California Subscriber Answer: Treat the confirmatory consultations as entirely different beasts than other consultations. Ophthalmologists perform confirmatory consults (99271-99275) when patients ask for a second opinion or when another physician requests a confirmatory consultation.

Also, anytime an insurer or a governmental, legislative or regulatory body requests a confirmatory consultation by a specialist to determine medical necessity before agreeing to cover a procedure or service, you should report a confirmatory consult code and append modifier -32 (Mandated services).

Caution: Medicare's "Routine Services" policy prohibits payment for services required by third parties:

"Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting or changing eyeglasses; eye refractions; hearing aids and examinations for hearing aids; and immunizations are not covered."
 
The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury, and (b) examinations required by third parties such as insurance companies, business establishments, or government agencies.