Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist saw an inpatient and treated her for diabetic retinopathy that had gone untreated for years. She also had glaucoma and cataracts, so the physician was with her for quite a while. He reported a 99233, which we’ve never billed before. How do I know if this high-level code is justified?

Answer: Code 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient…) is the highest level of subsequent hospital care, and the documentation requires two of these three criteria: a detailed history, detailed exam, and/or high-complexity medical decision making (MDM).

Of the three E/M components — history, exam, and MDM — you must fully document two components meeting the level of the E/M code selected to justify use of each subsequent care code. If there is little or no documentation, then you need to change the code.

If your physician performs and documents high-complexity MDM along with a detailed exam, this supports a 99233. But if the documentation falls short on both of the other two elements and doesn’t justify the level of care using time as the key component, even if the doctor says he did more than what’s on paper, then it’s an appropriate time to go over the essentials of thorough documentation with all of the practitioners in your office.

Tip: You can also report 99233 based on time if you meet the documentation requirements. CPT^® assigns a 35-minute time threshold to this code. Although many coders think of time-based E/M coding only as an outpatient strategy, it’s perfectly acceptable to use time as your overarching code selection criteria in the inpatient setting, if you meet the guidelines.

Ensure that the following three factors are documented in the hospital record if you select 99233 based on time: The total visit time at the bedside and on the floor directed toward the patient’s care (which should be at least 35 minutes), the time spent counseling/coordinating care, and a description or summary of the counseling/coordination of care provided.

For instance, “Saw the patient for 35 minutes face-to-face; 20 minutes of that visit was spent counseling the patient and her daughter about her diabetic retinopathy, glaucoma, and cataract diagnoses; potential treatment options and prognosis; answered multiple questions and provided them with educational information.”

Best practice: In order to select time, more than 50 percent of the total visit time must be spent counseling/coordinating care. Otherwise, you must rely on the key components for visit level selection.