Sharronka0312
New
Hello everyone! I normally code for Neurosurgery but have been asked to take on Ophthalmology as well. Any help or tips would be greatly appreciated. 
I do have some questions on what codes that I can bill when our doctors are seeing patients in the hospital ED/Inpt/Outpt (professional side).
Is it better to code E/M visits and not Eye Exam codes for the ED when patient is being seen for a medical problem (eg. blunt trauma to eye; conjunctivitis, etc.)?
When seeing the patient in Inpt and Outpt setting, can I report the Fundus photography if performed? (92250) and if this is allowed to report what documentation needs to be reported on the note in order for me to code 92250?
Dilated Fundus Exam--example: Anterior Segment--limited exam with penlight exam, pt was kicking and frequently moving arms. Dilated Funduscopic Exam (DFE) - Dilated with cyclomydril eye drops, both eyes. See MAR in EMR for timing, instilled by nursing staff. Per nurse, she put them into both eyes around 12:45 PM today _10/26/23_. Upon ophthalmology arrival to patient room, patient was not in room and was reportedly in Xray. Patient's nurse also reported that it was difficult to get the dilating eye drops into the right eye. Right eye less dilated. Additional cyclomydril eye drop placed into the right eye ~2:45 PM - discussed with nurse and notified primary team. Patient okay for dilation of both eyes per consulting team. Side effects of dilation discussed with consulting team, nurse and patient's mother in detail. Dilating eye drops generally last for several hours and gradually return to baseline.
Would this warrant me to be able to code 92132 with a 99221-99223/99251-99255?
I just feel like I am missing CPT codes when patients are seen in the ED/Inpt/Outpt setting and I want to make sure I am looking at notes properly and coding the correct codes to get reimbursement. So any help or current information listed on other sites would be so beneficial to me.
Hope you all have a blessed day!
Thank you,
Kelly Sharron, CPC
I do have some questions on what codes that I can bill when our doctors are seeing patients in the hospital ED/Inpt/Outpt (professional side).
Is it better to code E/M visits and not Eye Exam codes for the ED when patient is being seen for a medical problem (eg. blunt trauma to eye; conjunctivitis, etc.)?
When seeing the patient in Inpt and Outpt setting, can I report the Fundus photography if performed? (92250) and if this is allowed to report what documentation needs to be reported on the note in order for me to code 92250?
Dilated Fundus Exam--example: Anterior Segment--limited exam with penlight exam, pt was kicking and frequently moving arms. Dilated Funduscopic Exam (DFE) - Dilated with cyclomydril eye drops, both eyes. See MAR in EMR for timing, instilled by nursing staff. Per nurse, she put them into both eyes around 12:45 PM today _10/26/23_. Upon ophthalmology arrival to patient room, patient was not in room and was reportedly in Xray. Patient's nurse also reported that it was difficult to get the dilating eye drops into the right eye. Right eye less dilated. Additional cyclomydril eye drop placed into the right eye ~2:45 PM - discussed with nurse and notified primary team. Patient okay for dilation of both eyes per consulting team. Side effects of dilation discussed with consulting team, nurse and patient's mother in detail. Dilating eye drops generally last for several hours and gradually return to baseline.
Would this warrant me to be able to code 92132 with a 99221-99223/99251-99255?
I just feel like I am missing CPT codes when patients are seen in the ED/Inpt/Outpt setting and I want to make sure I am looking at notes properly and coding the correct codes to get reimbursement. So any help or current information listed on other sites would be so beneficial to me.
Hope you all have a blessed day!
Thank you,
Kelly Sharron, CPC