Ophthalmology and Optometry Coding Alert

When a patient is going through a narrow angle attack (365.22) or an angle closure attack (365.20), the work of the ophthalmologist can be difficult and time-consuming. But the ophthalmologist can be paid for that work, providing he or she documents well.

Glaucoma (365.xx) occurs when aqueous (water-like) fluid has difficulty passing through the area where the iris and cornea come together (the trabecular meshwork). During a narrow angle or angle closure attack the area becomes completely blocked, and pressure can build up quickly. Usually, the eye is quite painful. There even may be nausea and vomiting. These are emergency situations, but can be treated in the office. Nevertheless, the patient may be in the office for hours.

Jon Winders, clinic coordinator for Umpqua Valley Eye Associates in Roseburg, Ore., describes two very similar scenarios, one in which he was able to optimally code and the other in which he could only code minimally with the difference due entirely to documentation.

Scenario 1: The first scenario took up most of the ophthalmologists day, but resulted in an inability to bill more than a fifth-level office visit due to lack of documentation. The woman had an anatomically narrow angle (365.22), says Winders. Sooner or later, we knew she would have an attack. The doctor advised her to have a laser procedure 66761 (iridotomy/iridectomy by laser surgery [e.g., for glaucoma] [one or more sessions]) but she declined due to a planned trip. A few days later, she got a narrow angle attack. She was very sick, Winders recalls. She was vomiting and in a lot of pain.

The patient was in the ophthalmologists office all day. In addition to having glaucoma, the patient was a diabetic (250.x) and risked further problems because she couldnt keep any food down. The ophthalmologist gave her an antiemetic to help with the vomiting, but was not able to do the laser surgery. By the end of the day, the ophthalmologist called the patients primary-care physician (PCP), who admitted the patient to the hospital using the diabetes diagnosis. If the ophthalmologist had admitted the patient, the only charge the ophthalmologist would have been able to use for the entire day would have been a hospital admission code (probably a 99223). As it turned out, the ophthalmologist could bill a 99215 (office or other outpatient visit for the evaluation and management of an established patient). The ophthalmologist failed to document the time he spent with the patient and all the services he performed for the patient.

Winders could not bill 99058 (office services provided on an emergency basis) or 99358 (prolonged evaluation and management service . . . first hour) and 99359 (each additional 30 [...]