Optometry Coding & Billing Alert

Published on Fri Jan 07, 2005 PDF

Question: A patient had her past medical records, containing more than 10 years of history, sent to our optometrist for review. Not all of the history related to her current condition. How can I charge for my doctor's time reviewing these records?

Nebraska Subscriber

Answer: CPT considers reviewing records as an integral part of the E/M service, and you should not bill for it separately.

Although CPT does not include the time associated with records review in the time component described in the E/M codes, "the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys." Consequently, the service described by the E/M codes "is a valid proxy for the total work done before, during and after the visit," CPT says.

On the other hand, if your optometrist reviews the records and writes a summary of those records, you may be able to raise the level of medical decision-making. This would, in turn, allow you to choose a higher-level E/M service if you combine the E/M service with the history and examination.

Medicare gives two points for summarizing medical history. For instance, if your optometrist also orders and reviews old fundus photos, then the data category for medical decision-making increases to multiple. If the risk to the patient is moderate, you should report moderate-complexity medical decision-making.

When combined with a detailed history and examination, this is a level-three new patient service (99203, Office or other outpatient visit for the evaluation and management of a new patient ...) or a level-four established patient service (99214, Office or other outpatient visit for the evaluation and management of an established patient ...).