Ophthalmology and Optometry Coding Alert

Although ophthalmologists frequently provide consultations, properly reporting these E/M services remains a persistent coding challenge especially now that the Office of Inspector General has listed consultations as one of the investigative focus areas of 2003 for even the most savvy of coders. Consultation codes pay better than most levels of office visit (E/M) codes and eye codes, which is incentive for ophthalmology coders to learn how to use them appropriately. As with E/M services, ophthalmology coders should choose consult codes according to the three elements of history, examination and medical decision-making. But to bill consultations, physicians must also meet other important criteria that are not as clearly delineated. And if consultations are not properly documented, payers may confuse them with referrals or transfers of care, a road that leads straight to denials. Locate Correct Consultation Codes CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275). The first step to choosing a correct consultation code is to identify the location of the consult, choosing between an office or other outpatient setting (i.e., ambulatory facility or rest home) and an inpatient setting (i.e., hospital, nursing facility or partial hospital setting).

Suppose a patient presents to her ophthalmologist, Dr. Smith, complaining of blurry vision. He discovers that the patient is diabetic, with a family history of diabetes with ophthalmic manifestations, specifically cataracts. During his examination of the patient, Smith discovers leaking ocular arteries and swelling of the patient's retina and suspects that his patient is in the early stages of diabetic macular edema. He calls a fellow ophthalmologist and retina specialist, Dr. Pricey, and requests that Pricey give his opinion and advice on the evaluation and management of the patient.

To code Pricey's ensuing office consultation, you have to choose a code from the 99241-99245 series, depending on the level of the consult, if there has been an official request for the consultation, a documented reason for the consultations, and a written report sent to the attending physician the requirements for a consultation (see "Meet Consultation Requirements With the Three R's"). The outpatient consultation codes do not have outlined restrictions on their frequency of use, and it is not necessary for the patient to present with a new problem for an additional consultation code to be appropriate, according to the CPT 2002 guidelines. And typically, when a patient returns for an additional consultation, the patient has a problem unrelated to the problem behind the initial consultation, or the patient will return if the initial problem has developed into a more serious one, says Jennifer C. Simpson, CPC, a coder in Lexington, Ky. If an [...]