Ophthalmology and Optometry Coding Alert

Question: We've recently been seeing so many drop-in appointments - referrals from primary-care physicians and our nearby hospital (they don't have all of the equipment that we have) - that we're adding an emergency visit code to the patient's bill. Our physicians are always booked, so we're looking for a way to receive compensation for the fact that we're dealing with this overload, since it usually means stretching us into off hours. How do you think carriers will handle this?

Virginia Subscriber

Answer: The answer, as is the case with so many carrier circumstances, is: It will depend on the carrier. You're likely to see one of the following reactions:  Some carriers will deny it outright - as uncovered service. Some might provide reimbursement. Other carriers will deny, including the emergency service within the overall E/M service.

CPT code 99058 (Office services provided on an emergency basis) is one of a series of codes (99050-99058) from the "Special Services, Procedures and Reports" section of the handbook. The codes in this set describe different circumstances for the delivery of services that adds an extra element to the standard service (for example, emergency service, Sunday service, etc.).  In your circumstances, you should consider charging patients up-front for the additional fee and making it the obligation of the patients to seek payment from their insurance company. Most insurance companies have different payment rules for emergent care, such as not requiring the patient to go through the referral process and charging the patient a different copay amount.

In the case of Medicare patients, the "extra" charges are not covered, and you are not able to seek that payment from the patient. On the bright side, if you perform a service in a facility setting, which the ER is, Medicare will pay you at the "facility" rate, which is typically 20 percent less than what you receive for performing the same service in your practice. To avoid any problems in future audits, make sure that your files include the nature of the emergency, the medical necessity of the service, the service rendered, and the fact that the patient came in without an appointment.