Ophthalmology and Optometry Coding Alert

'Lack of medical component' distinquishes POS 33

An ophthalmologist in your practice visits a rest home to evaluate a new patient with blurred vision. How should  you choose from the nursing facility, rest home or home services CPT codes to accurately report the visit?

When ophthalmologists visit patients in rest homes, you may be tempted to report either nursing home or at-home service codes, but this can get you into hot water. There is a better way: Access CPT's dedicated rest  home codes.

For 2006, CPT revises its guidelines for services the physician provides to domiciliary, rest home or custodial care patients. And you don't have to worry about learning another set of guidelines, because the rest home codes mimic those you regularly apply for office or other outpatient visits.

Watch Your Place of Service

Before you submit rest home codes, you have to understand what differentiates the rest home, domiciliary or custodial care facility from other, similar places of service.

Specifically, the rest home, domiciliary or custodial care facility (POS 33--as defined by both CPT and CMS--"provides room, board and other personal assistance services, generally on a long-term basis."

Such facilities do not have a medical component, which distinguishes them from a nursing facility (POS 32), says Marvel J. Hammer, RN, CPC, CCS-P, CHCO, president of MJH Consulting in Denver.

Private residence doesn't count: You should use the home service codes 99341-99350 only when the physician provides E/M services to a patient in his "own private residence and not any type of facility," according to CMS rules.

This would mean that even if the patient is truly "at home" in the domiciliary or rest home, you would not use 99341-99350, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at a multiphysician practice in New Brunswick, N.J.

Out With the Old, in With the New

You won't be using 99331-99333 to describe services for custodial care patients after Jan. 1, 2006. CPT has deleted these codes and added nine new codes to describe services that the physician provides in rest home settings:

• 99324-99328--Domiciliary or rest home visit for the evaluation and management of a new patient ...

• 99334-99337--Domiciliary or rest home visit for the evaluation and management of an established patient

The AMA designed the new codes "to better capture the level of care provided in these settings consistent with increase of patients with complex disease who are eligible for this type of care ... [and] remain in non-medical facilities," according to the AMA's CPT Changes 2006: An Insider's View.

Apply Office Visit Rules to Rest Home Codes

CPT makes it easy: You'll choose from among 99324-99337 almost exactly as you would choose among office outpatient visits 99201-99215, Hammer says.

For instance, to report the lowest level new patient visit in a rest home, your physician will need to document a problem-focused history, problem-focused examination and straightforward medical decision-making (MDM)--exactly the same requirements for a level-one E/M service for a new patient visit in the office (99201, Office or other outpatient visit for the evaluation and management of a new patient).
 
As with the new patient office/outpatient visits, you must meet all three requirements to report a given level of service with new patient custodial care codes 99324-99328.

Example: Your ophthalmologist visits a new patient in a domiciliary for an evaluation. The physician documents a comprehensive history and exam and MDM that qualifies as "low complexity."

In this case, you must choose 99325. Although the comprehensive history and exam point to 99327, this code requires MDM of moderate complexity. Because all three components must meet or exceed the requirements of the chosen service level, 99325--not 99327--is correct.

2 of 3 Meets the Need for Established Patients

For an established patient, you need only meet or exceed two of the three requirements to report a given level of service. Once again, this mirrors the long-standing guidelines that apply to established patient office/outpatient visits, Hammer says.

Example: The ophthalmologist returns at a later date to evaluate the patient in the above example for a new complaint. The service consists of a problem-focused history, a detailed exam, and MDM of moderate complexity. In this case, you can select 99336--even though a problem-focused history does not meet the requirements of that service--because the physician has documented the remaining two requirements (a detailed exam and MDM of moderate complexity).

Watch for: "Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code," the Medicare Carriers Manual states. "The volume of documentation should not be the primary influence upon which a specific level of services is billed."

"Medical necessity and MDM can be considered the same in most cases," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. "Therefore, if MDM is low but history and exam are comprehensive for an established patient, I would defer to the level of service supported by MDM."