Ophthalmology and Optometry Coding Alert

Question: Our new coder is having a hard time understanding the difference between a level 4 and level 5 office visit and which code to use for each. An existing patient with new cataracts recently came in one year after their initial operation. The provider conducted a comprehensive history and a comprehensive exam. Should I code for a level 4 or a level 5 office visit? Which codes are associated with each level?

Texas Subscriber

Answer: This office visit would technically qualify as a level 5 visit based on the two of three elements rule as defined by CPT^®. That is the history and examination met the required comprehensive history and examination for code 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …). However, the nature of the presenting problem and medical decision making (MDM) supported in the note should be assessed as documented before assigning the appropriate CPT^®. You’ll find 99215 in Appendix C of the CPT^® code book with various clinical examples and can used as a guide to further support your rationale for code selection, but also isn’t by itself enough.

Let’s break it all down. Typically, a level 5 visit includes a comprehensive history, which requires a chief complaint; a complete past, family, social history (PFSH) (requires two of the three); an extended history of present illness (HPI) (requires four or more elements); and at least 10 systems reviewed (ROS). Also make sure a comprehensive exam was performed, which for 1997 guidelines should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected (of note – there are different requirements for a comprehensive exam in the 1997 guidelines based on whether a general multi-system or single organ system examination is performed. The requirements listed are for a general multi-system exam. See the 1997 Documentation Guidelines for Evaluation and Management Services for additional details and requirements for a comprehensive single organ system exam).

For 1995 guidelines, an exam of 8 or more organ systems or body areas meets requirements for a comprehensive exam. Level 5 visits also include MDM meeting high complexity, where the provider must consider management options and review significant patient data in order to determine the best course of action. In this case, the restaging justifies the use of code 99215.

Level 4 visits are not as complex. Though a detailed history needs to be taken, only two to nine systems need to be included for the ROS and one relevant piece of data needs be reviewed based on the patient’s PFSH. The exams performed at level 4 should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least 12 elements identified by a bullet (•) in two or more organ systems or body areas for 1997 guidelines or an exam of 2-7 organ systems or body areas with one in greater detail for 1995 guidelines (again, be sure to see the 1997 guidelines for additional details and requirements for a detailed single organ system exam). Level 4 office visits involve moderately complexity MDM, which is when a provider focuses on a single area of a patient’s complaint to determine the best course of action. In cases like these, the code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity ...) is acceptable.

Lastly, if this is a Medicare patient, or one where the third-party explicitly follows Medicare guidance for assigning the correct level of care, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code.” (Claims Processing Manual, Chapter 12, Section 30.6). Assigning the code based solely on the CPT^® requirement of meeting the two of three element is not always enough to justify code without considering the overall nature and medical necessity complexity of the visit.