Ophthalmology and Optometry Coding Alert

Question: We had a patient’s son present to talk about his mother’s glaucoma, the implications if it worsens, what his options are for treating her, and how to deal with her medication non-compliance? How can we bill for this visit?

Codify Subscriber

Answer: The answer will depend on which insurer covers the patient. According to CPT^® rules, if the patient’s family members present to the practice to discuss the patient’s condition with the ophthalmologist, you should report the visit based on time that the family members spend with the doctor using an E/M code from the 99201-99215 series.

Because the doctor is performing counseling based on an active condition that the patient has, you are justified in reporting the appropriate E/M code based on face-to-face time counseling or coordinating care. When you’re billing based on time, CPT^® defines “face-to-face time” as “only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.” Because CPT^® uses the language “with the patient and/or family,” it’s clear that the patient need not be present to report these codes under CPT^® rules.

The rules change if Medicare’s involved: Although CPT^® rules support reporting the E/M codes without the patient present, CMS states that the patient has to be present. Therefore, in cases where the ophthalmologist meets with the family of a Medicare patient and the patient is not there, you cannot bill for the service.