Optometry Coding & Billing Alert

Question: Another physician asked my optometrist to provide a consultation on a patient. The patient has many problems, including diabetes, COPD, and hypertension. Because of the presenting problems, may I code a level-four office consult (99244)?

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Answer: Consultations as an E/M category require meeting all three key components, not just the medical decision making level. You must code the level of service on the "lowest" key component -- that is, if the provider performed and documented a detailed history, but performed and documented a comprehensive exam and moderate decision making, the provider still can't report a level-four consult code.

Likewise, if you have a comprehensive history but only detailed or expanded problem focused exam, again there is no level-four consult.

Exception: If the provider spends more than 50 percent of the visit in counseling and coordination of care (C/C) with the patient, then C/C is the determining factor, not the three key components. To help in case of an audit, document the time the exam began and ended to show the extended time of the visit.

The documentation requirements for a level-three consultation are a detailed history, detailed exam, and low-complexity decision making. The documentation requirements for a level-four consultation are a comprehensive history, comprehensive exam, and moderate decision making. Although a higher level of decision making is one factor in the level of service, it is certainly not the only factor.

Although your optometrist is correct to document additional problems that have an impact on his level of medical decision making, even though he is not treating those problems, this is not enough by itself to support coding 99244.

Answers to You Be the Expert, Reader Questions and Build a Better Business reviewed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas.