Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist often spends nearly an hour speaking with patients when they have questions about chronic conditions such as glaucoma or diabetic retinopathy and the physician always reports an E/M code based on history, exam, and medical decision-making instead of time. We explained to him that he could report higher codes or prolonged service codes, but he doesn’t write down the amount of time spent because he isn’t willing to do the extra documentation. How can we explain the benefit of time-based coding to him?

Answer: When the time spent during the E/M visit is dominated by counseling rather than performing the key components of history and examination, CPT^® permits selecting the level of E/M services based on the total face-to-face time, as long as all of the documentation supports it. Specifically, if more than 50 percent of the total encounter time was spent counseling the patient, you might be able to choose an E/M code with time as a key factor, instead of considering the history, physical, and medical decision-making.

The coder must remember to check the notes for evidence that face-to-face time and counseling time are in the record, as well as the total visit time and what the doctor discussed with the patient and/or the family. If notes indicate a possible counseling exception, the notes must include sufficient detail regarding the counseling content to warrant selecting the E/M by time.

If your ophthalmologist refuses to document these factors, you have to revert to using the codes based on the documentation. You might want to keep track of the time the doctor spends counseling the patients, and then share the information with the doctor, discussing how much reimbursement he earned for the code he reported versus how much he would have collected if he’d coded based on time instead. This might persuade him to begin documenting his time more carefully.  

Prolonged codes can only be billed in addition to E/M codes when the counseling time meets the highest level E/M code in the category of E/M being billed (99205 or 99215, for example).  Therefore, if the physician spent at least 70 minutes with a patient where greater than 50 percent of the face-to-face time was spent in counseling and he documents total time, “greater than 50 percent was counseling” and sufficient detail as to the content of the counseling, you could potentially bill CPT^® code 99215 and CPT^® code 99354. This is a significant opportunity for compliant revenue capture and should not be ignored.