Ophthalmology and Optometry Coding Alert

Question: Can an ophthalmologist bill for a written report to the patient's physician who originally referred the patient to us? If so, what special codes or additional information do we need for reimbursement? Nebraska Subscriber Answer: If a patient has been "referred" to your ophthalmologist by, for example, his primary-care physician, you don't need to provide or have documentation of any further communication with the referring physician to bill for your services. You may be confusing referrals with consults, services which do require a written report to the physician who requested the consultation. According to the American Medical Association's guidelines, "The consultant's opinion and any services that were ordered or performed must be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source."

For referrals in the office setting, you should report a new patient office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or a new patient eye code (92002 or 92004, depending on the documentation). For a consultation, you should choose the appropriate-level service from one of the four types of consultations listed in CPT: office or other outpatient, 99241-99245
initial inpatient, 99251-99255
follow-up inpatient, 99261-99263
confirmatory, 99271-99275. Remember: The documentation must meet all three elements (history, exam and decision-making) for consultation codes. Also remember that the consult codes are E/M codes. If the referral results in a 920xx eye code, do not report a consult-level eye code. Don't code separately for the report your physician provides to the referring physician -- that work effort is included in the total reimbursement for the consultation range of codes. However, if a third party (an attorney, for example) were to request a written report from your physician, you could use code 99080 (Special reports such as insurance forms, more than the information conveyed the usual medical communications or standard reporting form) to report the service.