Ophthalmology and Optometry Coding Alert

CMS Transmittal 1644, issued in August 1999, revised Section 15506 of the Medicare Carriers Manual to clarify that physicians may charge a consultation and go on to treat the patient. Carriers must pay for a consultation code (99241-99245) if three criteria are met: 1) the consultation must be provided by a physician whose opinion or advice regarding a specific problem is requested by another physician, 2) the request must be documented in the patient's medical record, and 3) the consultant must send a written report to the referring physician.
 
Carriers must pay for the consultation regardless of treatment initiation unless care is transferred, according to the revision. If care is transferred, the visit would not be a consultation, but rather an office visit (99201-99215) or an eye service (92002-92014). (For more on consultations, see page 82 of the November 1999 Ophthalmology Coding Alert.)
Scenarios
In choosing between an office visit, a consultation, and an eye exam code for a new patient, remember that consultation codes and new patient office visit codes require documentation of all three key components: history, examination and medical decision-making. This requirement does not exist for eye codes, a consideration when reimbursement rates between comparable codes are similar.
 
Note: We have given recommendations for levels of services in the following examples. But when you determine a level, documentation is essential. Regardless of the circumstances and work performed, if these are not appropriately documented, the levels of service will not be justified, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses.
Blurry vision, patient needs glasses: A patient may be referred for a problem that is not covered by insurance. For example, an internist refers a 67-year-old woman to an ophthalmologist for "blurry vision." When the patient arrives, she also asks to have her eyeglass prescription checked. The patient is informed that a refraction is a noncovered benefit with a separate fee, to be paid by the patient. The ophthalmologist, after an examination, finds all is normal, except that the patient has incipient cataracts and needs a new eyeglass prescription. He writes a note to the internist explaining his findings. Bill 99243 and 92015 for the refraction, which the patient will have to pay for. This problem doesn't meet the criteria for level four, so 99243 is the highest level that can be billed. The other coding choice is new patient eye code 92004. Consider carrier documentation requirements and reimbursement to choose between 92004 and 99243.
Cataracts: In another example, the same patient, after being examined by the ophthalmologist, is found to have significant cataracts. The ophthalmologist writes a note to the internist detailing his findings and [...]