Ophthalmology and Optometry Coding Alert

Question: An ophthalmologist in our practice saw a patient for flashes and floaters and referred them to the retina surgeon, also in our group practice. Later that day, the retina specialist examined the patient, performed extended ophthalmoscopy, and surgically repaired the retinal detachment (67108). The patient has Medicare. Are both office visits billable in this scenario?

New Jersey Subscriber

Answer: In this case, you should only report one office visit since both providers are in the same specialty — ophthalmology. Having different subspecialty training does not change this rule. When multiple providers of the same specialty in the same group see a patient on the same day, choose a code that represents the combined value of the visits. Consider any repetitive or duplicate elements only once. Work out compensation for each provider internally through payroll.

The National Correct Coding Initiative (NCCI) edits bundle extended ophthalmoscopy with surgery when performed on the same day, so that’s not separately billable.

Do this: Submit the appropriate evaluation and management (E/M) or eye visit code with modifier 57 (Decision for surgery) to indicate that this was the office visit to determine the need for surgery. The payer must process the claim for payment rather than include it as a preoperative service.

Note, it’s appropriate to append modifier 57 in this case, as the E/M occurred the day of the operation and prompted a major surgical procedure (90-day global period).