A Day in the Office

Compliance and reimbursement optimization in the retina practice.

A Day in the Office

Compliance and reimbursement optimization in the retina practice.

Many retina specialists consider surgery as their main source of revenue and deemphasize coding for office visits and diagnostic testing. This creates 2 problems — lack of proper chart documentation for compliance and failure to optimize reimbursement. This review outlines some of the more important areas that the physician should be involved in. The rules expressed are from Medicare.

The Consultation Codes

Consultation codes reimburse significantly higher than a comparable office visit code at the same level in Evaulation and Management (E/M) coding. For example, a level 4 consultation code in 2006 has a national average (nonfacility) of $165.32 vs a level 4 new patient office visit reimbursement of $130.96 Most initial encounters by a retina specialist are considered consultations; however, there are strict rules for coding and billing consultations that must be adhered to. On Dec. 16, 2005, the Centers for Medicare & Medicaid Services (CMS) issued Change Request 4215, Transmittal 782, as part of the Medicare Claims Processing Manual. The category of second opinion consultations (CPT codes 99271-99275) was eliminated. This is a critically important document.

Request. Prior versions of CMS consultation documentation guidelines never stated that the request had to be in writing. In this transmittal, it is clearly stated that (bold print indicates new material):

"A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.

"The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient's medical record and included in the requesting physician or qualified NPP's plan or care. The consultation service request may be written on a physician order form by the requestor in a shared medical record."

This last paragraph has been interpreted to mean the consultant is responsible for the requesting physicians' documentation, ie, that the request be in the requester's chart. The Physician's Regulatory Information Team, a group of CMS experts who work on regulatory matters, has clarified that Medicare does not expect the consulting physician to verify that the requesting physician has documented the consultation request in the patient's medical record.

I have spoken to Medicare carrier medical directors over the years, and some have told me that they make it a routine practice to look for the documentation in the requester's chart that a consultation was actually requested in the requester's chart documentation. In my opinion, this is critical for chart documentation in intraoffice consultations.

Report. A written report of the findings and recommendations has always been required. Previous versions of this transmittal were unclear and contradictory in dealing with whether a separate written report would have to be produced within a group practice. This document clarifies that in a large group practice (academic department or large multispecialty group) in which there are often shared medical records, separate reports are not required. A caveat for those of you who write reports to members of your group: It is a good idea to continue doing that. It does not have to be lengthy — just a brief notation of the clinical findings and clinical disposition. Technically, it is not required but is a good safety precaution. At minimum, there should be a dated, initialed notation that the results were reviewed.

Tips: Here are some tips to help you:

► Another physician or appropriate source must request your opinion or advice — otherwise it is not a consultation.

► Consultation codes are E/M codes and if you are going to use them you must follow the E/M guidelines — no exceptions. I usually advise against using level 5 consult codes — not because you do not have that level on certain patients, but simply because it is an invitation to audit.

► Develop a request form for outside referrals for the consultation that can be faxed to your office and that clearly states a consultation is being requested. Especially for your most frequent referrers, request they keep a copy in their chart. Treat this as an insurance referral for front desk purposes.

► Develop an intraoffice consultation request form that specifies it is a consultation request, lists the date and reason for consultation, and identifies who the requestor is. Its presence in the chart should be religiously checked for by the consultant before proceeding with the consultation.

► A written report must be provided to the requesting physician. For intraoffice consultations (consultations among members of the same group), the shared medical record allegedly suffices; however, it is better to do a short note to protect yourself under audit.

► Payment may be made regardless of treatment initiation — be it surgery or medical. Diagnostic services and treatments may be initiated at the initial consultation service or at subsequent treatment. This has been a misunderstood concept for many years.

► You must have performed the 14 required elements of the exam in addition to extended ophthalmoscopy if you are billing a level 4 or higher. The extended ophthalmoscopy does not count for the required exam elements of optic disc and posterior segment and the ophthalmoscopy.

► Be sure to use a forced entry examination form (one with check boxes), and document negatives as well as positives. Mark boxes individually. Do not use squiggly lines — an auditor may interpret that as passing through the elements and not having performed them. See my Web site for a sample (

► If you use a separate history form, be sure it contains all the organ systems that need to be reviewed for a comprehensive E/M history and not just disease entities. When using a separate form, the physician must sign off on the form and review it with the patient or it does not count.

► Do not use "PRN" as your management disposition. This muddles whether the next patient encounter can legitimately be considered a consultation if the patient is referred again for a different problem or encounter.


Many diagnostic tests listed in CPT are used daily in a retina practice. Usually you can bill for office visit encounters and the diagnostic tests on the same day, though you need to review your carrier's local coverage determinations (LCDs) to ensure that you are in compliance. Some carriers limit the use of some diagnostic tests in the global period.

Extended Ophthalmoscopy

Tips: Here are some tips to help you:

► This is a designated as a unilateral test, meaning that the provider is paid separately for each eye. Therefore, there must be medical necessity for each eye, ie, signs and symptoms attributable to each eye. Good medicine does not equate to medical necessity for Medicare; thus performing bilateral testing when there is a unilateral problem to ascertain that the other eye does not exhibit any problems is not reimbursable.

► A separate interpretation and report is necessary. This is a written narrative report — not a labeled drawing.

► The drawing should be anatomically specific to that patient.

► The drawing should not be able to be considered a sketch. Provide a detailed drawing, preferably with some colors, clearly labeled, and of sufficient size (usually 3 inches to 4 inches in diameter).

► Be sure to check your Medicare carrier's LCD for this test. If one is not available, try following Empire New Jersey (

Interpretation and Report Requirements

All the ophthalmic diagnostic tests require an interpretation and report except for a few, such as gonioscopy. This is not a scribble on the back of the OCT. It is a report that addresses clinical findings, comparative data, and clinical management. For further information on this, visit my Web site and read the article entitled "The Three C's" under the category "Diagnostic Tests."

Empire Medicare has amended many of its LCDs concerning retina tests to emphasize that the interpretation and report should address the clinical management. Medicare wants to know how this test is going to help you with the management of this patient. How do you know something might be in the audit pipeline? An LCD revision may herald such an event.

Diagnostic Testing

Tips: Here are some tips to help you:

Rules. You must abide by your carrier's LCD on such issues as frequency, chart documentation requirements, and acceptable CPT and ICD-9 codes. Also, be sure to keep up to date with the edits in the National Correct Coding Initiative.

Diagnosis. There must be an appropriate diagnostic reason (and diagnosis) for any test that is ordered. For example, some scanning computerized diagnostic imaging (SCODI) policies (this code includes OCT) do not incorporate retina diagnoses, in which case the physician must use the unlisted CPT code for diagnostic tests, 92499.

Familiarize yourself with which codes are unilateral and which are bilateral. Be sure to bill for each side for unilateral codes and also make sure there is medical necessity for testing each side.

You must have an audit trail in your chart when you are viewing tests such as fluorescein angiography sitting in your office using digital imaging. I have consistently found when auditing that there is no audit trail and often no interpretation and report. After audit, monies have been paid back to various insurers because of this.


In the retina practice, laser procedures are the most common procedures performed in the office setting. Medicare defines an operating room as a laser suite, an endoscopy suite, or an operating room in a hospital or ambulatory surgery center.

Tips: Here is a tip to help you:

► Make sure your laser is not in a patient examining lane. In order to use modifier 78 (Return to Operating Room for a Related Procedure During the Global Period) you must perform the procedure in a room defined as an operating room according to the Medicare definition.


When a major or minor procedure is performed in conjunction with an office visit, you must use a modifier to assure payment for both the office visit and the procedure.

Tips: Here are some tips to help you:

► Minor procedures are defined as those with a global period of 0 or 10 days. If an office procedure is performed on the same day as the office visit (for example, intravitreal injection and office visit) you must append modifier 25 in order to get paid for both.

► If your chart note says "Return for injection," for example, then you do not have medical necessity to bill both the office visit and the procedure since the reason for the encounter was for the procedure and not a separately identifiable encounter, unless the patient has new complaints or a new problem.

► Modifier 57 is used to generate payment for an office encounter and a surgical procedure that is deemed major by Medicare (global period of 90 days). If the procedure is performed within 24 hours of the initial decision to do the surgery, then modifier 57 is the proper one to use.


Medicare audits have become more and more pervasive and physicians are likely to witness an increase for chart requests by various government audit agencies. It surely has become more difficult to maintain a balance between compliance and reimbursement optimization. Physicians must ascertain that both of these goals are being achieved in their practices.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at