Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist spent a total of 50 minutes with an established patient and completed an expanded problem-focused history and examination ...quot; enough to qualify for a level-three visit with 99213. But he also noted that he started counseling the patient about her macular degeneration at 3:15 p.m. and stopped at 3:45. Since more than half the time was spent in counseling, can I code 99215 for this visit?


Oklahoma Subscriber
Answer: Probably not, since the ophthalmologist did not specifically document that he spent 30 minutes counseling the patient. It's better to document the total minutes spent in counseling, rather than the beginning and end times.

The counseling does not have to be continuous; for instance, a physician may get called out of a room for a quick emergency, then return to the first patient to complete the visit and the counseling. Even though the counseling started at 3:15 and ended at 3:45, if the ophthalmologist spent 10 minutes on an unrelated emergency, you can't count that time as face-to-face counseling time.

According to CPT guidelines, if counseling and/or coordination of care constitutes more than 50 percent of the physician/patient encounter, you may use time as "the key controlling factor to qualify for a particular level of E/M services." CPT stresses, however, that to code by time the physician must clearly document:

• what the counseling consisted of

• the total time of the face-to-face encounter with the patient

• how much of that time involved counseling. Example: The ophthalmologist's note might say, "I spent a total of 50 minutes with the patient today, of which 30 minutes involved counseling her on treatment options of her macular degeneration. I fully explained and discussed the risks and benefits of the different treatments available."

Since he clearly documented that he spent more than 50 percent of the total time in counseling, you can report 99215, which states in its definition, "Physicians typically spend 40 minutes face-to-face with the patient and/or family." Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, president of Practice Solutions, Santa Barbara, Calif.