Ophthalmology and Optometry Coding Alert

Although ophthalmologists frequently provide consultations, properly reporting these E/M services remains a persistent coding challenge especially now that the Office of Inspector General has listed consultations as one of the investigative focus areas of 2003 for even the most savvy of coders.

Consultation codes pay better than most levels of office visit (E/M) codes and eye codes, which is incentive for ophthalmology coders to learn how to use them appropriately. As with E/M services, ophthalmology coders should choose consult codes according to the three elements of history, examination and medical decision-making. But to bill consultations, physicians must also meet other important criteria that are not as clearly delineated. And if consultations are not properly documented, payers may confuse them with referrals or transfers of care, a road that leads straight to denials.

Locate Correct Consultation Codes

CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275).

The first step to choosing a correct consultation code is to identify the location of the consult, choosing between an office or other outpatient setting (i.e., ambulatory facility or rest home) and an inpatient setting (i.e., hospital, nursing facility or partial hospital setting).

Suppose a patient presents to her ophthalmologist, Dr. Smith, complaining of blurry vision. He discovers that the patient is diabetic, with a family history of diabetes with ophthalmic manifestations, specifically cataracts. During his examination of the patient, Smith discovers leaking ocular arteries and swelling of the patient's retina and suspects that his patient is in the early stages of diabetic macular edema. He calls a fellow ophthalmologist and retina specialist, Dr. Pricey, and requests that Pricey give his opinion and advice on the evaluation and management of the patient.

To code Pricey's ensuing office consultation, you have to choose a code from the 99241-99245 series, depending on the level of the consult, if there has been an official request for the consultation, a documented reason for the consultations, and a written report sent to the attending physician the requirements for a consultation (see "Meet Consultation Requirements With the Three R's").

The outpatient consultation codes do not have outlined restrictions on their frequency of use, and it is not necessary for the patient to present with a new problem for an additional consultation code to be appropriate, according to the CPT 2002 guidelines. And typically, when a patient returns for an additional consultation, the patient has a problem unrelated to the problem behind the initial consultation, or the patient will return if the initial problem has developed into a more serious one, says Jennifer C. Simpson, CPC, a coder in Lexington, Ky.

If an additional consultation is required for a given patient, be sure to include a detailed explanation for the subsequent consultation.

For example, suppose Dr. Pricey from the previous example sends a report back to Dr. Smith after the consultation stating that the patient is not in the initial stages of diabetic macular edema and instead has an infection that should be treated with antibiotics. However, two weeks later, the same patient returns with further decreased, blurry vision and she now has a new complaint of flashes. Smith, convinced that the patient may have a different retinal problem, a possible retinal detachment, once again calls Pricey requesting another consultation with the patient. Pricey's second consultation should also be coded using 99241-99245 depending on the level of consult he provides.

Coders, beware: These outpatient consultation codes, unlike the office visit codes 99201-99215, are not subdivided into new patient and established patient classifications. In fact, the definitions of these codes require that all three components of history, examination and medical decision-making be met before a level of consult can be assigned, regardless of whether the patient is new or established.

Multiple Inpatient Consults Influence Code Choice

Satisfying all three components before assigning both new and established outpatient consultation levels also pertains to inpatient consultations but only the first consultation provided by a physician to a given patient. Note the CPT guidelines that instruct coders to use only one of the initial inpatient consultation codes, 99251-99255, per patient admission. These guidelines direct you to use the follow-up inpatient consultations for any subsequent consultations requested by the attending physician and provided during the same patient admission.

The follow-up codes, 99261-99263, are used when the physician (other than the patient's attending physician) who conducted an initial consultation with a patient then recommends management modifications, for example, at the request of the consulting physician This follow-up consultation is considered an "established patient" follow-up inpatient consultation. The guidelines for these follow-up procedures indicate that only two out of the three components history, examination and medical decision-making need to be met to determine the level of consultation that was provided the same requirements as an established patient office visit.

In another example, an ophthalmologist is called into the hospital to evaluate a patient preparing to undergo strabismus surgery. The attending physician, employed by the hospital, is seeking advice on whether the patient should undergo a transposition procedure in the same encounter as strabismus surgery that will be performed on his medial rectus and lateral rectus muscles, 67312 (Strabismus surgery, recession or resection procedure; two horizontal muscles).

The consulting physician approves the concurrent procedures and, after the attending physician completes them, he requests that the private-practice physician monitor the progress of the patient during the immediate postoperative period. It is under these circumstances that the follow-up consultation codes are required.

Be Cautious of Transfer of Care and Referrals

In the past, some payers have not reimbursed consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans. But in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless of whether treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif.

But keep in mind: If a patient returns to a consulting physician "subsequent to the completion of a consultation" and "the consultant assumes responsibility for management of a portion or all of the patient's condition(s)," the follow-up consultation codes are no longer appropriate, according to CPT guidelines. Instead, use the established patient office visit codes, 99211-99215.

The Medicare Carriers Manual section 15506 further explains, "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance." "Referral," in this instance, is simply another term for transfer of care.

Although the terms "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms when requesting or describing a consultation, Tucker says. Auditors and payers may automatically consider "referral" or "consult and treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming the patient's complete care, and therefore may not reimburse for a legitimate consultation. A better choice when requesting a consult is to use language such as "Please examine patient and provide me with your opinion on his or her condition."

'Request' Rules Differ for Confirmatory Consults

Confirmatory consultations are an entirely different beast than their fellow consultation codes. These consults, 99271-99275, are for patients coming in requesting a second opinion, says Danielle Smith, CPC, coding specialist with Maine Eye Care Associates in Waterville, Maine. "Normally it is the patient requesting the consultation, but it can be the family or even the insurer," she explains. If the patient initiates the consultation, indicate the patient as the person requesting the second opinion, Smith says.

Anytime an insurer, a PRO, or a governmental, legislative or regulatory body requests a confirmatory consultation by a specialist to determine medical necessity before agreeing to cover a procedure or service, report the appropriate code (99271-99275) with modifier -32 (Mandated services) appended, or you can expect the claim to be questioned.

For instance, suppose it is the patient's insurer seeking a second opinion from another ophthalmologist instead of the attending physician before approving the strabismus surgery for coverage in the above example. This second ophthalmologist evaluates the patient in the hospital at the insurer's request and performs the necessary diagnostic tests to confirm or disprove medical necessity for the surgery. The session should be coded 9927x for the consultation, depending on the documentation, with modifier -32 appended. Code any testing service performed in addition to the consultation code.