Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists saw a patient in the morning for a LASIK evaluation. Then that afternoon the patient returned to see a different doctor, within a practice of several doctors, for a diabetes check that was not related to the first visit. Can we report both established patient visits?

Answer: This is always a difficult problem for coders. In general, most carriers will not reimburse for two office visits on the same day -- especially if they are for the same condition or problem, and the patient is seeing two physicians with the same specialty designation from the same practice. In your case, however, there are different diagnoses.

Carriers will likely question why the physicians could not see the patient for both the LASIK evaluation and the problem visit during the same office encounter. If the group of physicians is under one tax identification number, you will not be able to submit both E/M services provided on the same day.

Ask yourself: Was the LASIK consultation considered medically necessary, and therefore, is it a reportable service? If not, does the patient have insurance coverage for a LASIK evaluation? Many payers do not pay separately for this service. The reason for the visit (LASIK evaluation) is not the same type of vision evaluation as for glasses and contacts, although the ophthalmologist may perform much of the same workup. Other payers consider the LASIK consultation part of the pre-operative component of the LASIK procedure and not separately payable.

The reason for the visit is to evaluate whether the patient is a candidate for LASIK surgery with a discussion of the procedure, cost, etc. Many practices offering LASIK surgery include the evaluation as part of the procedure's cost or at no cost.

What to do: If your payer considers the LASIK evaluation part of the procedure and therefore not billable, you should be able to report the second ophthalmologist's service for the diabetes checkup. Otherwise, you would need to combine the work of both physicians and report one E/M service under whichever physician you select. However, you cannot combine work for non-covered services. Therefore, if the LASIK evaluation is considered non-covered, do not determine the level of E/M code assignment using the work performed during the LASIK consultation combined with the diabetes check.

Best bet: Ask the individual carriers how they want you to report multiple same-day office E/M visits, keeping in mind the reason for each visit (LASIK evaluation and problem visit by different providers). Your ophthalmologists' documentation must support medical necessity for both services with the corresponding diagnosis.

Tip: Remember to always report two hospital visits on the same day with one CPT code. Combine the work at both visits to determine the service level to code. You may keep this same coding principle in mind and follow it when you're also reporting two office visits on the same day.

When dealing with more than one diagnosis in the office setting, often the increased medical decision making for the two different diagnoses may lead to the documentation of a higher final level of care for the combined visits. Keep in mind, however, that medical decision making alone is not the only criterion you need to meet for the level of service.