Ophthalmology and Optometry Coding Alert

Question: During an office visit, my doctor performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?


Washington Subscriber
Answer: Report 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient. The patient's status changes the office-visit level - you must meet the requirements for two of the three components for established patient visits, but new patient services mandate that you meet all three components. And the documentation requirements for each level are not identical. A level-four established patient visit (99214), for example, requires a detailed history and exam and a moderate level of complexity. The same level of new patient visit (99204) requires a comprehensive history and examination and a moderate level of complexity.

New patient visits require all three key components, so you should report new patient E/M services based on the lowest component. In this case, the physician uses a problem-focused exam, which qualifies for 99201.
 
Report a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...) if the ophthalmologist evaluated an established patient. Disregard the lowest of the three components if billing an established patient visit. In the above scenario, you may ignore the problem-focused exam, which leaves you with low-complexity decision-making and an expanded problem-focused history. The two highest components of the visit meet 99213's requirements.

Watch for: A word of caution is given when determining the level of service for established patients. The Medicare Carriers Manual, Section 15501, states:

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."