Ophthalmology and Optometry Coding Alert

Question: One of our ophthalmologists saw a patient in the morning for a cataract evaluation. Then that afternoon the patient returned to see a different doctor, within a practice of several doctors, for retinal evaluation for diabetic eye disease that was not related to the first visit. Can we report both established patient visits?

New Jersey Subscriber

Answer: This is always a difficult problem for coders. In general, most payers will not reimburse for two office visits on the same day — especially if for the same condition or problem, and the patient is seeing two physicians from the same practice.

In this case, payers will likely question why the physicians could not see the patient for both the cataract evaluation and the retinal visit during the same office encounter. If the group of physicians is under one tax identification number, you will not be able to submit both E/M services on the same day.

What to do: If your payer considers the cataract evaluation part of a subsequent cataract surgery and therefore not billable, you should be able to report the second ophthalmologist’s service for the diabetes checkup. Otherwise, you would need to combine the work of both physicians and report one E/M service under whichever physician you select.

When dealing with more than one diagnosis in the office setting, often the increased medical decision making for the two different diagnoses may lead to the documentation of a higher final level of care for the combined visits.