Ophthalmology and Optometry Coding Alert

Question: The doctor is required to be present in an operating room when an ocularist measures a child (under anesthesia) for a scleral shell (15-30 minutes). What CPT code should be used for this service?

Nevada Subscriber

Answer: From the information given, the ophthalmologist appears to be present in the operating room observing, or on standby, should a problem occur requiring his or her services. According to CPT 2000, the only code to describe physician standby services is 99360 (physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG]). The instructional notes in the section of physician standby services, however, indicate this code is used to report physician standby service that is requested by another physician and that involves prolonged physician attendance without direct (face-to-face) patient contact.

The physician may not be providing care or services to other patients during this period. Code 99360 also is not used if the period of standby ends with the performance of a procedure subject to a surgical package by the physician who was on standby. It is used to report the total duration of time spent by a physician on a given date on standby. Standby service of less than 30 minutes total duration on a given date is not reported. Code 99360 would not describe a physician presence in the operating room at the request of an ocularist who is an allied health professional, and the duration of the standby you describe is less than 30 minutes. Therefore, there is no specific CPT code to describe this service.

Another consideration is the diagnosis or medical necessity for the ophthalmologist to be present in the operating room. Who or what entity is requiring the physician to stand by during the ocularists services? What is the medical necessity for the surgeon to stand by? To receive reimbursement from payers, there must be a diagnosis (medical necessity for rendering the service) as well as a CPT code. There also must be appropriate documentation by the physician to describe the service rendered. Without documentation of the service performed, it cannot be charged and billed. It is suggested the physician who is in the operating room be consulted about the exact service that is rendered, review the physicians documentation of it and the medical necessity for performing the service to code it accurately.

According to CPT, when there is no specific code to describe the service rendered, you may use the unlisted procedure code in the correct anatomical section. In this case it would be under the eye and ocular adnexa section; however, there is no unlisted procedure code in the eyeball subsection. There is an unlisted procedure in the subsection for anterior segment, code 66999. When using the unlisted procedure codes, you should send the documentation of the service rendered with the claim to the payer. Do not code 99360 if the time spent in standby is less than 30 minutes.

Answers to Reader Questions and You Be the Coder provided by: Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology in Santa Barbara, Calif.; Lise Roberts, vice president of Health Care Compliance Strategies, a compliance and coding consulting company in Jericho, N.Y.; and Catherine Brink, CPC, CMM, president of Healthcare Resource Management Inc., a coding, compliance and reimbursement consulting company in Spring Lake, N.J.