Coding Q&A

Retina coding basics to help avoid audits


Knowing Retina Coding Basics Will Help Avoid Audits


With the advent of the Medicare RAC (Recovery Audit Contractors) audits going into full swing, this month's column reviews some of the coding basics for the retina practice.

Definition of a New Patient. Medicare's revised definition of a new patient provides an opportunity for optimizing reimbursement. The new definition is a patient who has not been seen in the practice in a face-to-face encounter for three years. The difference from the older version is the addition of “face-to-face.”

For example, if the patient has not been seen in the practice but prescription medications had been renewed for the past three years, then the encounter used to be coded as an established patient. Now, since there was no face-to-face encounter, you can code the encounter as a new patient.

Revenue is lost by not paying attention to the last time the patient was examined in the practice. The differential in reimbursement between a new patient and an established patient is between 30% and 40%.

Consultations as Repeated Services. There has been some confusion regarding whether a consultation can be coded more than once on the same patient. The answer is yes, providing the chart documentation is excellent and medical necessity issues are met.

For example, your opinion and advice on the management of a patient presenting with a retinal detachment in the right eye is requested. You perform the consultation and, indeed, the patient does have a retinal detachment that requires surgical repair. The repair is performed. You discharge the patient after the appropriate time back to the referring comprehensive ophthalmologist. (Please do not use “PRO” as your disposition.)

If the patient then develops an unrelated problem in the other eye (ie, choroidal neovascularization) then the patient may be sent back to you for another evaluation and this may be coded as a consultation. Subsequent follow-up visits would be coded as established patient visits.

Extended Ophthalmoscopy: Sketch vs Drawing. The primary requirements of reimbursement for extended ophthalmoscopy are an extensive detailed drawing and the interpretation and report. Often, the question is posed whether or not extended ophthalmoscopy can be billed if there is no drawing. No, it cannot.

Furthermore, labeling is not an interpretation and report, and a quick sketch is not an extensive drawing. The drawing should be of sufficient diameter (3 to 4 inches), a few colors are always nice, and an adequate interpretation and report that addresses clinical management, clinical diagnosis, and comparative data needs to be part of the chart documentation. Many contractors have policies on this and you should check for yours.

Elements of the Examination. One of the most frequent reasons that a retina chart is downcoded is lack of performance and documentation of all 14 elements in an E/M (Evaluation and Management) level 4 or 5 service.

Retinal physicians tend to perform the 12 elements (excluding optic disc and posterior segment) up to dilation and then go directly to extended ophthalmoscopy. You cannot do this. All 14 elements have to be performed and then the extended ophthalmoscopy (which may have medical necessity for only one eye). If you do not document optic disc and posterior segment, then you will not be credited with those elements and the auditor will down-code the encounter.

Inadvertent Intravitreal Injection. Medicare recently released a Medicare Learning Network document on coding and billing for errors of wrong procedure and/or wrong body part and/or wrong patient. It also includes billing instructions and modifiers. It can be found at: 2009MMAN under “Wrong Surgical or Other Invasive Procedure.” RP

CPT codes copyright 2006 American Medical Association.

Riva Lee Asbell can be contacted at where the order form for her new book Tips on Ophthalmic Surgical Coding by Subspecialty can be found and downloaded under Products/Books.