Ophthalmology and Optometry Coding Alert

Question: An established patient came in for a previously scheduled eye injection. The physician’s documentation mentions the prep and the procedure, but also mentions writing a script for an unrelated issue. The provider wants to bill for the evaluation and management (E/M) service. Is the prescription information going to be enough to support the E/M?

Ohio Subscriber

Answer: Unfortunately, the prescription is probably not enough to justify the E/M.

It’s common for providers to think a new prescription is proof enough of an E/M service when the patient is scheduled for a simple procedure. However, unless coding is based on time to justify an E/M, the physician would have needed to document at least two of the three elements of medical decision making (MDM).

Writing a prescription does not satisfy two elements. For example, the physician would need to document such things as the problem(s) addressed through evaluation and management, treatment options and course of treatment chosen, any medicine prescribed, any referrals made, and any plans for follow-up.

If coding is based on time, writing a prescription is still unlikely to fulfill the requirements. There would still be a need for documentation that satisfied even the lowest level of office/ outpatient E/M service, which involves a minimum of 10 minutes with the patient. Any payer would question a 10-minute-long encounter that only involved writing a prescription.

Note: Even if the physician supplied thorough documentation, reporting the appropriate level eye E/M (92xxx (Ophthalmological services: medical examination and evaluation …)) or office/outpatient E/M (99xxx (Office or other outpatient visit for the evaluation and management of an established patient…straightforward medical decision making…)) would not be enough. This is a job for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Be certain the note supports the separately identifiable service defined by use of the modifier.