Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist makes a follow-up visit to the hospital. It is for an established patient, but this is the first hospital encounter. It was not requested by the admitting physician. What is the appropriate CPT code?

California Subscriber

Answer: Selecting the appropriate evaluation and management (E/M) code for an inpatient service depends on the medical necessity (reason for the encounter) of the service and the medical record documentation by the ophthalmologist. Based on the information provided, your ophthalmologist is not the admitting physician. Therefore, you need to determine the reason why (medical necessity) the ophthalmologist was providing an E/M service. You indicated it was not requested by the admitting doctor so it cannot be a hospital consultation (99251-99263).

Because your physician was not the admitting physician, the initial hospital visit codes (99221-99223) are not appropriate either. These codes are for use by the admitting physician, and only one initial hospital visit is allowed per hospitalization.

You should speak to the ophthalmologist who rendered the inpatient service to determine why the inpatient E/M encounter was provided. If the ophthalmologist simply decided to check up on an established patient, there is no medical necessity for rendering the E/M service, and the visit is not billable.

There may have been concurrent care, which means two or more physicians are rendering follow-up inpatient services, not consultation services, on the same patient on the same day. Each physician then must have a medically necessary reason for their services the diagnosis. For example, the admitting physician may use a diagnosis of hypertension for his or her follow-up care, and your ophthalmologist may use a diagnosis of glaucoma (365.xx), but there still must be viable medical necessity for your ophthalmologist to be providing inpatient services or your payer will deny payment. Your ophthalmologist then would bill a subsequent hospital visit (99231-99233), even though it may have been his or her first time visiting the patient during the hospitalization.