Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist treated a patient with severe eye injuries due to a car accident. The doctor had a meetingwith other members of the treatment team, including a craniofacial surgeon and a neurosurgeon about the case. Is there a way to bill for this time talking to other doctors?

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Answer: Probably not if you see the patient that day. CPT^® states, "All levels of subsequent hospital care (99231-99236) include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status (i.e., changes in history, physical condition and response to management) since the last assessment." In addition, under the code descriptors in this series, CPT^® says, "Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs."

Therefore, it appears that CPT^® includes conversations with other physicians in the payment for the E/M codes. A typical subsequent inpatient visit might include your time with the patient, a review of her chart, a discussion with the charge nurse regarding the patient's behavior and/or interval history, and meeting with the rest of the patient's team of providers to discuss treatment plans and other issues. These items would all be part of the E/M code, which would be determined based on the complexity of the individual case.

The rules would change, however, if you were discussing a patient but you were not visiting the patient that day. Although most government payers won't pay for any physician encounters that don't involve face-to-face time with the patient, you may be able to get reimbursement from private payers by coding for team conferences, if you are dealing with an interdisciplinary team. This depends on the various payers' guidelines, so contact your insurer before reporting these codes. Look to the codes in CPT^®'s Medical Team Conferences range (99367-99368) when reporting these services.

Keep in mind, however, that in the preamble to the Medical Team Conferences codes, CPT^® says, "Physicians or other qualified health care professionals who may report E/M services should report their time spent in a team conference with the patient and/or family present using E/M codes (and time as the key controlling factor for code selection when counseling and/or coordination of care dominates the service."

In addition, CPT^® states, "No more than one individual from the same specialty may report 99366-99368 at the same encounter" and also says, "Individuals should not report 99366-99368 when their participation in the medical team conference is part of a facility or organizational service contractually provided by the organization or facility."  

Ensure that their documentation appropriately describes the meeting participants, the treatment plan, and proof of the time spent discussing the patient before billing private payers.