Ophthalmology and Optometry Coding Alert

Question: How can we bill for preoperative exams given by the ophthalmologist or technician?

Colorado Subscriber

Answer: Billing for preops must have supporting documentation from a previous visit stating that the preop is necessary for medical reasons. If you are going to bill this as a clearance for surgery exam only, with no other problem, the ophthalmologist must document the medical necessity for the exam. This documentation should be done during the encounter previous to the one in which the preoperative exam is done. The notes for that date should clearly indicate that the physician wants the patient to return so he or she can check some medical problem prior to surgery, such as poorly controlled hypertension or a pulmonary problem that needs to be cleared close to the surgery date.

Do not use two diagnosis codes for the preoperative examination. This is precisely why people are routinely denied payment for preoperative visits. Use the diagnosis code that corresponds with the systemic medical condition for which they are being seen. If its cataracts and the surgery has already been scheduled, it is not a medically necessary visit and the carrier would appropriately deny the service as preoperative and included in the global.

The chart note could be as simple as Patient needs to return for evaluation of diabetes and presurgical clearance. It may be that the ophthalmologist does not feel qualified for this evaluation or that the patients condition requires the expertise of a cardiologist or internist. In that case, the cardiologist or internist can access the consultation codes (99241-99245) when clearing a patient with known systemic conditions prior to surgery. A routine clearance, in the absence of systemic conditions, would not be covered separately, and the ophthalmologist should do the clearance as part of the global surgical package. The global surgical package allocates 10 percent of the total global payment for preoperative care. For a routine screening or visit to discuss the surgery with the patient, a separate charge should not be submitted to Medicare for payment. Only certain patients will have medical conditions necessitating an additional billable service. If you bill a preoperative visit for every patient prior to surgery, you will be waving a red flag to an auditor that says, I am violating the global surgery package.