Ophthalmology and Optometry Coding Alert

Scenario: A patient calls her ophthalmologist, who is part of a large group practice, to make a routine appointment, telling the receptionist that she has had a few bothersome problems lately, including occasional flashing lights. The history reveals that the patient has been having flashes and floaters for several weeks. Upon examination, the ophthalmologist discovers a retinal tear, and refers the patient to a retinologist who is in the same practice. The retinologist performs surgery the same day. How would the coding staffer for this practice code for the services provided?

One big question here is whether you can bill for both the visits with the general ophthalmologist and the retinologist on the same day. If they were in different practices, you could, but this question becomes complicated because they are in the same group.

You can indeed bill for both physicians with many insurance plans, according to M. Robin Fox, HCRM, director of reimbursement for Eye Centers of Florida, a 30-provider multi-office practice based in Ft. Myers, FL. If the ophthalmologist performs a routine exam and learns of the complaint of flashes and floaters during the course of the exam, the ophthalmologist would bill for an eye exam, says Fox. You would use either an E/M office visit code (99201-99215) or an eye code (92002, 92004, 92012, or 92014). The retinologist would then bill a consult code (99241-99245), says Fox.

But theres a lot of controversy about billing a consult code within a single practice, Fox warns. We believe that you can do it if the physician is a sub-specialist, such as a retinologist, says Fox, noting that with Medicare in Florida, there usually wont be a problem doing this. With some private carriers and some Medicare carriers and Medicare HMOs, however, you will not get paid for both encounters, she states.

In that case, you would want to get paid for the consult only, since it pays at a higher rate. You would use the referring ophthalmologists UPIN as the referral, but you wouldnt bill for the visit itself, says Fox.

Consult or Transfer of Care?

The use of a consult code for the retinologist when billing Medicare is further complicated by a recent update in the Medicare Carriers Manual (MCM) to Section B3 15506, regarding consultations (99241 - 99275), says Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY. This section states, When the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally (i.e., a request to evaluate and treat), the receiving physician may not bill a consultation. He or she bills a visit. The rule is then further complicated by the instruction to the carrier to pay for the consultation if the referring physician does not transfer the responsibility for the patients care to the receiving physician until after the consultation is complete.

Most of the Medicare carriers, says Roberts, have been interpreting this update to mean that it is the intent of the referring physician which determines whether the service is a consultation or a visit. Since many ophthalmology sub-specialists have patients referred to them without the benefit of either a written or verbal communication from the requesting physician, how can they tell if it is a request for a consultation or a transfer of care?

Noting that the retinologist has a lot of work to do, preparing the patient for emergency surgery, Fox says a consultation code would certainly be appropriate for most insurers. The alternative would be for the retinologist to use an office-visit code instead of a consultation code, she says.

Weve done a lot of research on when you can use consult codes, Fox notes. In ophthalmology, theres a great deal of consulting between sub-specialists. But that doesnt mean its not consulting. In general, if you treat a patient, youre not doing a consult, she says. But if you call the referring ophthalmologist back and say, `This is what I think we need to do, and then the original physician gives the go-ahead to do the surgery, you can still be considered as providing a consultation.

Also in this case example, the retinologist has to use a modifier -57 on whichever code he usesoffice visit or consultsays Fox. Modifier -57 indicates that the physician is providing an evaluation and management service that is resulting in the decision to perform surgery. This means that the modifier -25 is not necessary, even though two E/M services are being billed on the same day.

Finally, the retinologist, even if in the same practice as the general ophthalmologist, would always have to see the patient before doing the surgery, says Tracie Mann, reimbursement specialist with the Washington, DC-based George Washington University Medical Faculty Associates, where there are 10 ophthalmologists. The specialist cant do the surgery without first talking to the patient, under Medicare rules, says Mann. And a lot of times, private insurance will have the same rule, she adds.

This wouldnt be an issue if the general ophthalmologist and the retinologist were in two different groups, says Fox.

We talked to a retinology practice which gets such referrals from general ophthalmologists, and an ophthalmology practice which makes such referrals to retinologists, for their views on this issue.
We send lots of patients to retinologists on the same day, says Rhonda Weiss, office manager for Thomas Weiss, MD, an ophthalmologist in Miami Beach, FL. We can still bill for what we do, she notes. If the patient had fluorescein or fundus photos, we will bill for all of that too, she says. Its never a problem.

And William Stinson, MD, a retinologist based in Beverly, MA, agrees. Biller Linda Camire says that normally, the ophthalmologist would refer the patient to the retinologist for the fluorescein. The retinologist would then use an E/M services code with a -57 modifier, if he is deciding to do the surgery and does the surgery within one day of the decision.