Ophthalmology and Optometry Coding Alert

Answer: The H&P performed on the same day as the decision for the cataract surgery is billable. However, your physician may bill only one E/M using the combined work of the eye exam and additional work to perform a full H&P.  

 

It would not be appropriate, however, to bring the patient back to the office for another office visit prior to the surgery to do an H&P. Once the decision for surgery has been made, any additional visits prior to the surgery are considered part of the surgical package and not separately billable unless the patient had new problems or worsening problems that necessitated evaluation.  

 

Good idea: Your physician check with his malpractice carrier to make sure he is not stepping outside of the role of an ophthalmologist to perform the full H&P normally done by a PCP.  

According to Medicare’s National Coverage Determination for Use of Visual Tests Prior To and General Anesthesia During Cataract Surgery, “In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used. 

 

“Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented.”