Ophthalmology and Optometry Coding Alert

Question: A patient was referred by an ophthalmologist in our practice to an optometrist in our practice for low vision consultation. When do we need to get a waiver, and what is the correct way to code?

Tennessee Subscriber

Answer: Low vision aids are not covered by Medicare. Low vision consultations, however, are. Low vision is a condition in which the patient is considered functionally blind usually a best corrected vision of 20/200 or worse. Low vision patients usually have macular degeneration (362.50), retinitis pigmentosa (362.74) and other retinal conditions that can affect the central vision. If the patient has a vision rider insurance plan, there may be coverage for the low vision aids.

A low vision optometric consultation (99241-99245) to determine whether visual aids might assist the patient is covered by Medicare and other payers. An ophthalmologist or optometrist spends a long time perhaps an hour with the patient discussing activities of daily living and devices that can be used to assist reading, television viewing, etc. The only thing that can be billed is a visit (99211-99215) or consultation. The time spent fitting and the supply of the aids is not a benefit of the Medicare program. Only the time spent in the discussion with the patient may be included in the selection of the appropriate consultation code. Remember that when time is the key component that determines the code selection, the essence of the discussion must be documented along with both the total time spent with the patient and the discussion portion of that total time. In an audit of medical records, the auditor has to be able to determine whether more than half the total time spent was in counseling or coordination of care. That is the criterion for coding based on time instead of the documentation of history, examination and medical decision-making.

An ophthalmologist or optometrist would be paid for his or her services based on documentation of the disease that causes the central vision impairment. This establishes the medical necessity for the consultation.

Technically whenever you suspect Medicare wont pay for a service, you need an advanced beneficiary notice (ABN) to be signed before the service is rendered. Have the patient sign an ABN form if you intend to bill him or her for the fitting and supply of the low vision aid(s). State in the ABN that The Medicare program does not cover the fitting and supply of low vision aids as the reason why you believe Medicare wont pay. Medicare does allow for a portion of a service to be billed to the program that is a covered portion (i.e., the consultation), and a portion that is not covered by Medicare (i.e., the fitting and supply of low vision aids) can be billed to the patient.

While some optometrists specialize in low vision treatment, ophthalmologists provide the service as well. In the case of an ophthalmologist, the technician often provides the service. But consultations cannot be billed for a strictly technician service, so the only way to bill them would be to use 99211 (office or other outpatient visit for the evaluation and management of an established patient), which does not require the presence of a physician during the performance of the services. Of course, 99211 could only be billed providing that incident to guidelines are followed. For incident to services, Medicare requires a physician to be on premises when an assistant is providing a service under the physicians orders. To qualify for incident to services, the procedure must be integral to the doctors diagnosis or treatment, be provided under the direct supervision of a physician, performed by an employee of that doctor, and ordinarily done in a doctors office or clinic. Direct supervision requires the physician to be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing the services. If the ophthalmologist provides the consultative portion of the service and the technician does the fitting and supply, the consultation codes could be used to bill Medicare.

Note: For more on incident to, see related story, Receive Appropriate Reimbursement for Technician Services