Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist saw a newborn in the hospital as a consult and found the patient to have congenital cataracts. The doctor did an exam, history and such, so that day is easy to code. The following day, the doctor went back and spent 30 minutes with the newborn's mother and grandmother explaining everything that needs to be done and talked to the specialist. How should I code for the second visit considering there was no exam component at all?

Washington Subscriber

Answer: When your ophthalmologist spends more than 50 percent of the time with a patient and/or family/caregiver on counseling and coordination of care, you can use time as the sole factor in choosing the correct code to report. You'll match the time your physician spent on the encounter to the average time listed in the appropriate E/M service section. You don't need to consider history, exam, medical decision-making or the presenting problem.

Keep in mind: Counseling includes discussions with the patient and/or family about diagnostic results, prognosis, treatment risks and benefits, instructions for management, compliance issues, risk factor reduction, and/or patient and family education. Coordination is discussions about the patient's care with other providers or agencies. In the case you describe, the ophthalmologist performed both counseling and coordination of care for the newborn.

Key: Your physician's documentation must be very specific about the time he spent with the patient's family and what sort of counseling and coordination of care he provided.

Tip: When time is the prominent factor in your E/M code choice, you should realize that you calculate that time differently depending on the place of service. For inpatient care, as in this case, you report based on unit/floor time, which includes all work the ophthalmologist performs on behalf of the patient while present on the unit or at the bedside, such as reviewing records and talking with family members or other professionals. In the outpatient, non-facility setting, time includes only face-to-face time with the patient.

Bottom line: In this case, your ophthalmologist spent 30 minutes with the patient's family, and he spent more than 50 percent of that time on counseling and coordination of care. Therefore, you should report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for this encounter.