Ophthalmology and Optometry Coding Alert

Question: When an ophthalmologist who is a non-hospice provider performs a medical visit at a hospice patient's home, how should I code the service? Medicare is denying these services as noncovered.


Georgia Subscriber

Answer: You should report home services (99341-99350) with the appropriate HCPCS modifier. For a home visit to a new patient, assign 99341-99345 (Home visit for the evaluation and management of a new patient ...). When the ophthalmologist treats an established patient at home, use 99347-99350 (Home visit for the evaluation and management of an established patient ...).

Append the home service code with modifier GV or GW based on:

1. the condition the ophthalmologist evaluates and manages

2. and whether the physician is a hospice provider.

Here's how: If the ophthalmologist provides services related to the hospice patient's terminal condition, you should use modifier GV (Attending physician not employed or paid under arrangement by the patient's hospice provider).

Caution: Reserve modifier GV for cases in which the hospice service doesn't compensate the ophthalmologist.

When the ophthalmologist treats a patient for a condition that is unrelated to a terminal illness, you should assign modifier GW (Service not related to the hospice patient's terminal condition).

Important: You can use this modifier regardless of whether the physician works for the hospice. Also, be sure to list the patient's home as the place of service, and list the patient's address on the claim form.

Example: An ophthalmologist sees an established patient who's on hospice for lung cancer to treat elevated intraocular pressure (365.01, Borderline glaucoma [glaucoma suspect]; open angle with borderline findings).

Because the ophthalmologist treats the patient for a condition (high IOP) unrelated to his terminal illness (cancer), you should attach modifier GW to 99347-99350.

For the ICD-9 code, report the high IOP diagnosis (365.01), rather than the cancer diagnosis (such as 197.0, Secondary malignant neoplasm of respiratory and digestive systems; lung). The physician's hospice status doesn't affect the modifier usage.

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, CPC, president of Practice Solutions, Santa Barbara, Calif.