Ophthalmology and Optometry Coding Alert

Question: An established senior patient presented to the office for a follow-up evaluation and management (E/M) visit for their bilateral anterior subcapsular polar age-related cataracts. After examining the patient’s eyes and reviewing their history, the ophthalmologist discussed the option of cataract surgery with the patient. The patient agreed to proceed with the surgery, which was scheduled for one month from the visit.

With the potential loss of vision and the decision to undergo surgery, would this E/M visit fall under a level 5?

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Answer: No, this visit doesn’t meet the criteria for a level 5 E/M code, such as 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.).

According to the American Academy of Ophthalmology, in order to meet the criteria for a level 5 E/M code, the patient would most likely be experiencing a traumatic cataract that required emergency surgery. When determining the level of medical decision making (MDM), two of three elements must be met to assign a corresponding E/M level code. For example, a level 5 E/M code would require an “injury that poses a threat to life or bodily function” and for the physician to decide about emergency surgery.

A traumatic cataract, which is a cataract that occurs due to blunt force, foreign objects penetrating the eye, radiation, electrical shock, or a chemical injury, can result in loss of vision in one or both eyes without immediate medical attention.

In your case, the patient presented with a chronic condition that was progressing and the physician and patient decided to move forward with minor surgery, which meets the threshold for an E/M visit with a moderate level of MDM — or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate 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.).

Mike Shaughnessy, BA, CPC, Production Editor, AAPC