The most common acute anterior segment conditions that O.D.s see include inflammatory, infectious and allergic conditions or minor trauma to the eye. Here, we review the proper procedures for coding and billing when a patient with an acute anterior segment condition walks in your office.
The doctor must accurately translate the patient history, level of physical examination and medical decision-making to determine the CPT code level that most accurately describes the services actually performed. For most (but certainly not all) patients who present with a red eye or minor trauma, you can use a level 2 or level 3 992XX evaluation & management (E/M) code or an intermediate 920X2 ophthalmologic code. The components inherent in a 920X2 code vary slightly from state-to-state, but taking a history, assessing acuities, and performing and recording a proper slit lamp exam will satisfy these requirements in most cases.
Billing for a 992XX code is more complex, so pay particular attention to follow the Documentation Guidelines for Evaluation and Management Services published by the Centers for Medicare & Medicaid Services (CMS). (The most recent guidelines, from 1997, are the most commonly followed.)
For new patients, 99203 or 99202 are the most common codes. Code 99203 requires a detailed history, a detailed examination and medical decision-making of low complexity. Code 99202 only requires an expanded problem-focused history, an expanded problem-focused exam, and straight- forward medical decision-making.
For existing patients, 99213 or 99214 are commonly used. However, the CMS program that monitors coding errors found that recordings in medical records often do not support 99214-level visits. So, if you code at that level, make sure that your records support the medical necessity of the elements counted. Code 99213 requires two of these three: expanded problem-focused history, expanded problem-focused examination, and/or low-complexity medical decision-making. Code 99214 requires two of these three: detailed history, detailed examination and/or moderate-complexity medical decision-making. Again, make sure that your medical records support the medical necessity of every countable element and that your medical decision-making is well documented.
Modifier -25: Be Cautious
While modifier -25 can be appropriate for acute anterior segment conditions, its often misused and can create unnecessary risk for the practitioner. Modifier -25 is used to designate a significant, separately identifiable E/M service provided by the same doctor to the same patient on the same day as minor surgical procedure. It should be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure, with a global fee period performed on the same day as the E/M service.
When using modifier -25, make sure you perform a significant, separately identifiable E/M service any time you perform another procedure or service. Be sure to thoroughly document the need for both.
Anterior segment issues are very commonplace in optometric practices. By adhering to well established coding fundamentals and by following published guidelines, you can more readily reap the rewards of providing medical eye care for your patients.
Correction
In Augusts Coding Abstract, The Birth of a CPT Code, we erred in saying that optometry has no representation in the process of originating a new CPT code. Currently, Douglas Morrow, O.D., serves as a CPT advisor, representing the American Optometric Association. Advisors do not vote for code approval, but they can submit codes for approval and comment on code proposals before the panel votes. Ophthalmology also has an advisor and does not have a vote on the current CPT panel. John Rumpakis, O.D., M.B.A., Clinical Coding Editor D.C. Dean, O.D. David Mills, O.D., M.B.A. Laurie Sorrenson, O.D.
Clinical Coding Committee
