Ophthalmology and Optometry Coding Alert

Know where to turn for straightforward MDM once 99241 is scrapped.

Be proactive and start familiarizing yourself with the new evaluation and management (E/M) guidelines for facility visits that you will see in 2023.

Context: To level-set and standardize E/M code level determination, the AMA is extending the revisions to code descriptors and guidelines enacted in 2021 beyond physician office and outpatient E/M services. These updates seek to provide continuity across all the E/M sections of CPT^®.

Keep reading for a review of the E/M changes CPT^® 2023 will bring about next year that will impact how your ophthalmology practice reports office/outpatient consultations.

Apply 2021 E/M Rules to Consultations Next Year

Among the changes set to take effect on Jan. 1, 2023, are revisions to inpatient and outpatient consultations. The facelift to these E/M subsections consists of headline, guideline, code, and descriptor adjustments that align with the 2021 E/M guideline changes to office/outpatient services.

Starting off, CPT^® has changed the wording in the consultations guidelines to allow “other qualified healthcare professionals” to perform E/M consultations in addition to starting diagnostic or therapeutic services during the visit or at a subsequent visit.

Turning to the office/outpatient consultations guidelines, you’ll find CPT^® has revised the places of service (POS) in the following way:

• CPT^® 2022: “… report consultations provided in the office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, or emergency department.”
• CPT^® 2023: “… report consultations that are provided in the office or other outpatient site, including the home or residence, or emergency department.”

Mandatory modifier: The guidelines also state that you should append modifier 32 (Mandated services) to a required consultation. For example, if a payer requests a consultation, such as a second opinion before the payer approves treatment, you should append modifier 32 to the applicable consultation code.

Review Office Consultation Code Revisions

The updated consultation codes will allow providers to select the level of service based on medical decision making (MDM) or time. Here’s a sneak peek at the revised office/outpatient consultation E/M codes for 2023 with portions of the revised descriptors emphasized for easy reference:

• 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.)
• 99243 (… low level of medical decision making … 30 minutes must be met or exceeded.)
• 99244 (… moderate level of medical decision making … 40 minutes must be met or exceeded.)
• 99245 (… high level of medical decision making … 55 minutes must be met or exceeded.)

Notably, references to the level of history and examination are deleted and substituted with “a medically appropriate history and/or exam,” which mirrors the changes made in 2021 to the descriptors for the outpatient visit codes.

Coding for prolonged services: CPT^® adds a parenthetical note after 99245, instructing you to use add-on code +99417 (Prolonged office or other outpatient evaluation and management service(s)…) for services lasting 70 minutes or longer. Don’t forget to check your individual payer policies, as rules and requirements regarding prolonged services coding may vary.

Descriptor modification: When the calendar flips to Jan. 1, 2023, you should also take note of the revision to the descriptor for code +99417. The new descriptor removes the language telling you the code can only be used in conjunction with 99205/99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …); instead, you will use +99417 with any of the highest-level E/M services that can be billed by total time if your payer accepts prolonged service billing using CPT^® guidelines.

If you’re billing an E/M visit solely on the basis of time, you can assign +99417 only after 15 minutes have elapsed beyond the minimum time required for the highest-level primary service. In the cases of office/outpatient consultations, you cannot assign +99417 until 15 minutes have passed after the initial 55 minutes of the 99245 consultation — in other words, 70 minutes total. Additionally, the 15 minutes of +99417 may count regardless of whether the provider was in direct contact with the patient.

Do this: Be on the lookout for possible forthcoming Medicare prolonged service codes. The feds will likely weigh in soon on whether you’ll continue to use G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure …) or a similar code, to be determined, with all the revised E/M codes that can be billed based on time for Medicare patients.

Key code deletions: In keeping with the level one office/outpatient E/M code deletions of 2021, CPT^® has deleted the lowest level office (99241) and inpatient (99251) consultation codes to align with four levels of MDM in 2023. Beginning Jan. 1, you’ll report 99242 for a consultation that involves straightforward MDM.

Follow These Pro Tips on Coding Consultations in 2023

What do practices need to know before billing outpatient consultations next year? We asked industry experts, and this is the advice they doled out. “As part of the 2023 revisions, this range of consultation codes can be documented through either time or MDM. History and exam, as with office visits, are no longer key components of consultations,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager at Eisner Advisory Group LLC in Iselin, New Jersey.

That means that come January, you’ll use either documented physician time or MDM to support your E/M consultation code choice. You should review your individual payer preferences, but as long as they don’t have specific additional requirements, you and your providers can decide how to support your code choice for the encounter.

What if you have a report that states the provider used a certain level of MDM, but the total time surpassed what’s assigned to the code for that level of MDM? “If the provider documents cumulative time along with the MDM and relevant history/ physical examination, the coder can select the method that benefits the provider,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Remember: The provider has the ultimate responsibility to document and select the code. “If the provider believes the encounter was especially lengthy, they may choose to document the time spent in various activities and select a code based on time,” Clark adds.

Example: The ophthalmologist performs an E/M service in which the documentation supports moderate complexity (99244), but the total time for the visit is 55 minutes (99245). In this case, you can report 99245 for the service providing your documentation can account for the total time spent performing face-to-face and non-face-to-face activities on the date of the encounter.

Take note: Documentation in the medical record should indicate how the physician time was spent — reviewing incoming records, obtaining a detailed history, performing an exam, education and discussion with patient and family, discussing patient status with another provider on the care team — a cryptic note (e.g., patient was in the office x 55 minutes) would likely be challenged in a payer audit.

For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.