Ophthalmology and Optometry Coding Alert

Avoid the ophthalmological services codes when time is on your side.

The great debate over whether to report E/M codes or ophthalmological service codes is simple to solve if your visit with a patient involves the doctor spending more than half of the visit counseling or coordinating care for the patient. Why? Because in these instances, you can typically report a higher-level E/M code than the history, exam, and medical decision-making warrant — as long as your documentation is pristine.

The scoop: When the doctor spends more than 50 percent of an E/M visit performing counseling or coordinating care, CPT® allows you to choose the level of E/M service based on the total face-to-face time, as long as all of the documentation supports it. This is not an option when you use ophthalmological services codes, because you cannot report those based on time. Use the following steps to ensure you follow the appropriate rules to report your visit based on time.

Step 1: Include 3 Items in Documentation

Before using time as the controlling factor, check off the following requirements that must be documented:

1. The total time spent with the patient.

2. The time spent counseling/coordinating care, which demonstrates that more than 50 percent of the face-to-face time the physician spent with the patient/and or family was counseling/coordination of care. For instance, “Saw the patient for 25 minutes face-to-face; 20 minutes of that visit was spent in counseling.”

3. A description or summary of the counseling/coordination of care provided. For instance, “Spoke with the patient and her daughter about her glaucoma diagnosis, potential treatment options and prognosis; answered multiple questions and provided them with educational information.”

Spot the Problem With This Documentation

Check out the following chart note and determine which E/M code you would report:

A 72-year-old patient is seen for a glaucoma (chief complaint/location-ophthalmologic system) FU (HPI-duration) visit. She has been on prostaglandin (HPI-modifying factor) for one month (HPI-duration) but feels her vision is worsening (HPI-severity). She is still having problems with seeing rainbow-colored circles when she’s driving (context) and with blurred vision (HPI-quality). She has not noted problems with head pain (ROS-neurological) or nausea (ROS-gastrointestinal). Physical examination consists of an ophthalmological examination (can’t give credit here as there are no details). Her son reports that she is not using the medication as often as it is prescribed, she says it is because the drops sting in the morning. Extensive counseling is done regarding whether she is taking the medication according to the instructions, the seriousness of her diagnosis of glaucoma and potential treatment options (counseling description). Advised that she take the medication at night instead of the morning and switched her medication to Xalatan to optimize the nighttime penetration (prescription drug management-table of risk-moderate) (MDM risk: 2 pts) and FU planned in one month. Total face-to-face time is 25 minutes.

Problem: Although the documentation in the chart indicates the encounter’s total face-to-face time (25 minutes), the ophthalmologist fails to indicate the percentage of the encounter that he spent on counseling and/or coordination of care, says Allison Anderson, owner of AAA Billing in Newark, N.J. “It’s impossible to calculate a percentage without both numbers, the time spent counseling and the total time,” she says.

CPT^® lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care. If the documentation does not specify that the encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service.

Step 2: Use Elements When Time is Unknown

In this case, because the time spent in counseling/coordinating care is unknown, you instead have to code the visit based on the documented history, exam, and medical decision-making, as follows:

History: Detailed

• HPI: location, quality, severity, duration, context, modifying factors — Extended
• ROS: Two elements: Neurological, gastrointestinal
• PFSH-Social: 1 element

Exam:

None that can be used in counting the elements.

Medical Decision-Making: Low

• Est. Problem worsening: 2 points
• Data: None
• Risk: Chronic problem worsening (moderate risk)

CODE: 99213 (History — Detailed and MDM — Low complexity).

Without knowing how much of the 25 minutes the physician spent counseling and without any documentation of the exam, the key documented elements support 99213, not 99214.

Solution: If the ophthalmologist had documented the actual time that he spent on counseling, you would have met the time-based coding rule requiring that greater than 50 percent of the visit was spent on counseling/and or coordination of care criteria, and you would have been able to report 99214.

Is a Consult A Third Option?

Many times, an eye care staff member will write “consultation” on a chart that includes a lot of time counseling or coordinating care. For instance, if a patient comes in for a workup after being diagnosed with diabetic retinopathy, the ophthalmologist might spend a long time counseling the patient and discussing the prognosis with the family. However, just because the word “consultation” is on the chart doesn’t mean you are meeting the requirements to report a consult code (99241-99245).

A true consultation occurs only when another physician or other appropriate source specifically requests the ophthalmologist’s opinion and advice, and the doctor sees the patient and subsequently writes a report back to the requesting physician with a diagnostic impression and recommendations for treatment. If the ophthalmologist is simply seeing a patient for a standard office visit but spends most of the visit in counseling/coordinating care, you’ll still bill a standard E/M code (99201-99215) based on time and not a consultation code.

Remember: Medicare doesn’t pay for consultations, so you shouldn’t report those codes to a Part B payer anyway. However, some private payers still reimburse for these codes.