Wiki Billing 99205 for an emergent SX

[Nlbell]

I work for a Retina Specialist in Colorado. I can't get an EM level of 99205 paid as medically necessary. If the patient came in and the provider has a MAC off tear that is emergent 24 hours before loss of sight. Why would this not qualify for 99205? I built the claim on the EM tool and 99205 was the EM level to bill. Any ideas??
From the denials we are seeing, I'm thinking that down coding is being promoted from payers because they don't want to pay to the level being provided.

 

[csperoni]

No ophthalmology experience at all, but breaking down the problem/data/risk, it would seem like:
Problem: high for acute illness that poses a threat to bodily function (loss of eyesight)
Data: straightforward for none
Risk: high for decision regarding emergency major surgery

If you have already submitted an appeal with your documentation, either:
1) The payor is incorrect and did not properly review the records
2) Your documentation is insufficient. Perhaps the surgery is a minor, not a major surgery. Perhaps the risks are not documented.

I did have a contract with one payor that specified only certain ICD10 codes would even be considered to pay level 5 visits. I hated that contact, but as a small practice, the payor was unwilling to negotiate - it was simply take it or leave it. That is another possibility.