Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist often does rounds at the hospital but rarely admits patients himself. However, the other day he did admit a patient and asked me to report the admit code. I can’t find it anywhere. Can you help?

Florida Subscriber

Answer: A common misconception involves whether you can find an admit code in the CPT^® code set, but you cannot — the initial inpatient code is what you should use when you admit a patient to the hospital.

The admitting physician should report a code from the 99221-99223 range based on what they document (appropriate history, exam, and medical decision making). The doctor is not billing for the admit itself — they’re billing for the initial care that they provide, based on the documentation.

CPT^® states that the initial hospital care codes “are used to report the first hospital inpatient encounter with the patient by the admitting physician.” However, Medicare (and Medicare Advantage plans) treat initial hospital care codes differently. Before 2010, only the admitting physician reported initial hospital care codes, and specialists who saw the patient separately billed inpatient consultation codes. Since CMS no longer recognizes the consultation codes, consultants may report initial hospital care for the initial visit from that specialty group during a patient’s stay.

In contrast, commercial insurers will only pay one claim per hospital admission with an initial inpatient code. For instance, the policy for Blue Cross and Blue Shield of Florida says it will pay “for one initial hospital care service per hospital stay per patient. If multiple claims are received with one of the initial hospital care services CPT^® codes, the first claim received will be allowed and the subsequent claim(s) will be denied with instruction to rebill with the appropriate subsequent hospital care code.” (Source: www.floridablue.com/sites/floridablue.com/files/docs/Initial_Hosp_Care_Eval_and_MGMT_Services_16-047-2020_0.pdf)

Private payers may still allow consultation codes for the non-admitting physicians of different specialties who are called in to assist with care. If the documentation meets consultation coding requirements, then 99251-99255 may be selected instead of 99221-99223.

Caveat: Because Medicare allows multiple specialists to charge for a patient’s initial hospital care, Medicare created modifier AI (Principal physician of record) to show which doctor admitted the patient. The other doctors seeing the patient for consultative services will charge for their services with a code from the same series but with no modifier to report their first visit with the patient.

Important: Make sure the patient your ophthalmologist attends has been admitted as an inpatient, since not all stays qualify as “inpatient” status. Even if the doctor saw the patient in the hospital, the stay may not meet criteria for admission as an inpatient.

If the stay only qualifies for observation care and the patient is seen for an initial encounter, Medicare and its followers require the ophthalmologist to use the new or established patient codes (99201-99215) since the ophthalmologist is the consultant and not the attending physician of record. Non-Medicare payers may allow the outpatient consult codes to be used (99241-99245), if recognized. The place of service on the claim in this situation is 22 (Outpatient hospital).