Ophthalmology and Optometry Coding Alert

When your ophthalmologist evaluates a patient at the request of an optometrist, and the patient returns to the optometrist for further care, do you code the encounter as a consultation? In 2010, the answer could be "yes and no." Although the AMA clarifies the transfer of care definition in the CPT book, Medicare did not feel another clarification was the answer to an ongoing problem with consultation coding. The decision to eliminate payment for consultation codes provided to Medicare patients was made after the AMA published the 2010 CPT books.

Whether private payers will follow suit is now a question and concern for health care providers.

The Office of Inspector General found a high error rate on appropriate use of consultation codes. Different opinions on when a transfer of care occurs versus a consultation caused $1.1 billion in incorrect payments. "We couldn't even all agree on some scenarios," admitted William J. Mangold, Jr., MD, JD, Medicare contractor medical director for Noridian Administrative Services (Arizona, Montana, Utah, Wyoming), in a session at the CPT and RBRVS 2010 Annual Symposium in Chicago.

Ophthalmologists who don't regularly code consults could gain from Medicare's decision not to recognize the consultation codes for payment in 2010. CPT still considers the codes valid. CMS, however, will take the relative value units (RVUs) for 99241-99255 (Consultations) and redistribute them to office visits (99201- 99215), hospital care (99221-99233), and nursing home (99304-99310) codes. This will create a 6-percent boost for the work RVUs for office visits and a 2-percent increase in work RVUs for inpatient E/M services from private payers that choose to adopt the 2010 Medicare Physician Fee Schedule.

The differing rules, however, spell trouble. "We are going into Dante's Inferno for 2010," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN  Healthcare Solutions and senior coder and auditor for The Coding Network in Tinton Falls, N.J. "We will have to manage who does and who does not allow consultation codes." Each payer may decide at will to reject or to accept 99241-99255.

Example: An optometrist asks an ophthalmologist to evaluate a patient who is presenting with chronic blurred vision with red, irritated eyes, and provide his opinion and recommendations for care. The physician evaluates the patient and reports his findings back to the optometrist. Although the ophthalmologist indicates he took the initiative to start treatment, the patient returns to the optometrist for follow-up and further care as needed. The encounter with the ophthalmologist is considered a consultation;

however, if the payer chooses to follow Medicare's lead and not recognize the consult codes, you would instead report an office visit code (99201-99215, Office or other outpatient service ...).

The requirements for consultation codes and new patient codes are the same. However, because the history, examination, and medical decision making components do not match up for established office visits and consults, the code level may be different. As before, auditors will have to determine which service (new or established office visit or consultation) the documentation supports.

Some large payers and small payers that do not base their payments on Medicare's fee schedule may not follow Medicare's lead. At the AMA CPT and RBRVS 2010 Annual Symposium in Chicago, a medical director indicated that at least one payer will continue to use consult codes. "Blue Cross Blue Shield of Rhode Island will accept either method," said Peter A. Hollmann, MD, the AMA CPT editorial panel vice chair in his "Evaluation and Management" presentation at the AMA symposium.

"I'm not sure how helpful our decision will be for you, considering how big a state Rhode Island is," Hollmann joked with attendees.

BCBS RI made this decision for two reasons:

1. "We wanted to allow physicians to report based on both CMS and CPT rules," Hollmann explains.

2. The contractor is not using the 2010 fee schedule because it can't implement the changes by Jan. 1, Hollmann reported. "Since we're not redistributing the relative value units" to pay office visits and hospital care services more in exchange for invalidating consult codes, "we won't change our consult policy."

Medicaid falls under CMS. Does that mean Medicaid will stop accepting consult codes as of Jan. 1? The answer "depends on the Medicaid program in your state," responded Kenneth B. Simon, MD, MBA, CMS senior medical officer, in the Q&A portion of "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the symposium. "You'll have to wait for instructions in your state."