Ophthalmology and Optometry Coding Alert

Know what to do when payers don’t accept consultation codes.

Last month, Ophthalmology and Optometry Coding Alert outlined the revised office/outpatient consultation evaluation and management (E/M) codes and guidelines in the AMA’s 2023 CPT^® code set. This article will provide a more nuanced analysis, along with some expert advice on how to choose the level of medical decision making (MDM), what to do when a provider initiates diagnostic testing during the consult, and if payers will even reimburse for consultations.

Ascertain What Factors Into MDM Level

When a patient visits your ophthalmology practice for a consultation, several factors influence your code selection. The patient may be experiencing multiple new or established conditions at the time of the encounter, but the number of conditions alone would not determine the level of MDM. However, whether the conditions are acute or chronic is likely a key factor. “The 2023 MDM is similar to the 2021 rules in that the ‘new or established’ conditions do not matter as much as whether those problems were addressed and managed,” 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: Selecting the level of MDM requires more than determining the number and complexity of problems addressed at the encounter. “With the revised MDM calculations, the coder must also consider the amount or complexity of data to be reviewed and analyzed, as well as the risk of complications or morbidity or mortality of patient management. Two of these three areas must meet or exceed the requirements for any given level in order to assign an E/M code,” adds Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager at EisnerAmper Advisory Group in Iselin, New Jersey.

Scenario: An allergist sends a patient with redness and flaky crusting along their eyelids and eyelashes to the ophthalmologist for a consult. The ophthalmologist determines the patient has an acute exacerbation of their chronic blepharitis and needs prescription management, as they have experienced several blepharitis exacerbations throughout the year. After the two physicians discuss patient management, the allergist decides to follow the ophthalmologist’s recommendations regarding drug therapy.

This case could qualify as moderate complexity since one chronic illness with exacerbation was addressed, there was discussion of management with an external physician, as well as prescription management.

Do This When a Consultation Leads to Diagnostic Testing

During an outpatient consultation, the consulting provider may decide to perform a diagnostic test to receive up-to-date results before providing a recommendation to the requesting physician, which is allowable per the AMA consultation guidelines

Not sure whether you can report the consultation and diagnostic testing codes together? Start by doing the following:

Step 1 – Prove medical necessity: Review the requesting physician’s documen­tation to ensure the diagnostic test and the E/M visit are both medically necessary and documented.

Step 2 – Check National Correct Coding Initiative (NCCI) and payer edits: Look through NCCI and payer-specific edit pairs to confirm whether your selected CPT^® codes are bundled and shouldn’t be separately reported at the same encounter.

Scenario: An optometrist requests that your ophthalmologist consult on a new patient and advise how to best manage and treat their chronic glaucoma. The ophthalmologist documents that since the patient is new to the practice and does not have any records documenting previous testing or care, it’s necessary to take several intraocular pressure measurements to establish a baseline for the condition before making any suggestions. After performing serial tonometry, your ophthalmologist recommends the patient continue latanoprost drops in both eyes nightly and return for repeat testing in six months.

For this visit, you’ll need to report the correct consultation code along with the serial tonometry CPT^® code. Depending on what was determined in the consultation visit and the associated MDM level, you may assign either of the following 2023 E/M codes:

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

Then you’ll assign 92100 (Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report …) to report the tonometry testing.

In this scenario, the ophthalmologist documented the need for serial tonometry during the consultation. Additionally, 92100 isn’t bundled with 99243 or 99244 in the NCCI edits (based on fourth-quarter 2022 edits), which means you can report the appropriate codes for the encounter.

Switch Up Your Coding for Certain Payers

Many providers misunderstand the CPT^® concept of consultations, and the codes are often used inappropriately, such as when a provider refers a patient to a specialist. “Per CPT^®, the key requirement of a consultation is that a physician or other appropriate source requests an opinion or advice from a physician; and that physician renders the advice and/or opinion back to the requesting provider,” Clark says. CPT^® revised the 2023 E/M consultation guidelines to eliminate the “transfer of care” term since the term may have caused confusion as to the appropriate use.

At the end of the day, the real question is if payers will even reimburse for consultations. “Medicare does not recognize consult codes, and will likely still not recognize them,” Pohlig says. This is due to, in part, the misuse and under-documentation of consultation codes.

If a payer doesn’t recognize consultation codes and a practice submits one, the practice will likely receive a denial indicating the procedure code is not covered. “In this case, the practice has the opportunity to identify the issue, correct the claim, and resubmit the appropriate new or established patient code,” Pohlig says.

For payers that do not accept consultation codes, you’ll report the eye exam with either a new or established patient E/M visit code (992xx (Office or other outpatient visit for the evaluation and management of a new/established patient …)) or a new or established patient ophthalmological services code (920xx (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment …)), depending on if the patient has received face-to-face services from a provider in the practice within the last three years, says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Do this: Make sure to review your individual payer policies to see how you should report office/outpatient consultations to receive proper reimbursement.