Optometry Coding & Billing Alert

Published on Wed Oct 20, 2004 PDF

Medicare's policy can make for tricky low-vision coding - but our expert advice will help you earn $53 per consultation

Low-vision examinations are time-consuming and work-intensive - and what's worse, if you're not following these little-known rules for reporting them, you're probably losing money.

With 2.4 million adults in America with visual impairments - a number that the National Eye Institute and Prevent Blindness America expect to double in the next 30 years - these services are going to become increasingly necessary. Optometrists who are trained to examine, treat and manage patients with uncorrectable impairments can greatly enrich a patient's quality of life. Here's what you need to know about coding these important services.

Use Time to Determine E/M Coding

Medicare has covered physician-prescribed rehabilitation services for visually impaired beneficiaries since 2000. Most low-vision rehabilitation programs begin with a low-vision examination. This usually includes an extensive history, assessment of ocular functions, visual acuity and visual fields. It also typically includes reviewing the various activities of daily living that are restricted by the patient's low vision and trying a variety of low-vision aids while instructing the patient on their proper use.

Even though the exam can take up to two hours, there is no specific code to claim reimbursement for it. Furthermore, Medicare won't pay for the low-vision aids, says Susan Unger, controller for the Center for the Partially Sighted in Los Angeles - and therefore won't pay for prescribing and fitting them. You can, however, bill an office visit (99211-99215) or consultation (99241-99245), Unger says.

Opportunity: You can use time, rather than the documentation of history, examination and medical decision-making, as the main factor in determining the level of E/M code to report, says Meladie Heinz, CPC, insurance and coding specialist for Eye Center of Colorado West in Grand Junction - as long as you spend more than half of that time in counseling and coordination of care.

Remember, however, that the time spent fitting and the supply of the aids is not a benefit of the Medicare program. You can only include the time spent in the discussion with the patient in the selection of the appropriate consultation code. The total time you spend must be equal to or greater than the "reference time" given in the CPT code description (for example, "Physicians typically spend 30 minutes face-to-face with the patient and/or family").

Document Time and Avoid Problems

When you use time as the key component to select a code, you must document the essence of the discussion along with both the total time you spent with the patient and the discussion portion of that total time. In an audit of medical records, the auditor has to be able to determine whether more than half the total time spent was in counseling or coordination of care.

Example: You perform a low-vision evaluation on an established patient. You spend a total of 20 minutes with her, and you document that you spent 15 of those minutes discussing low-vision aids and showing the patient how to use them.

Since you spent more than 50 percent of the total time in discussion, you can use time to determine the E/M code. Report 99213, which has a reference time of 15 minutes.

Protect yourself: Documentation is always crucial for time-based E/M services. You should specifically note start and stop times for the patient visit, Heinz says. Also note the portion of the time spent on counseling and coordination of care.

Don't Give Up on Coding for Low-Vision Aids

You can still code for low-vision aids even though Medicare won't reimburse you for them, Unger says. She bills Medi-Cal, California's Medicaid program, for the equipment with three HCPCS codes: