Coding Q&A


A Potpurri of Coding Questions Regarding Office-based Procedures

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Coding for office-based procedures and visits is the source of many questions I receive. This month, I’ll answer some of them.

Sometimes, office-based procedures are the most difficult to code as they often fall into gray areas that can be confusing to coders.

Q. I have a question about an inpatient. My doctor was asked to see a woman who was brought to the office while still an inpatient, and then taken back to the hospital afterward. What CPT code do I use? Do I use 99221-99223, even though my doctor was not the admitting doctor? What is the Place Service (POS)?

A. There are several intertwining issues here. For Medicare, either the eye codes or the E/M codes may be used. Several MACs (Medicare Administrative Contractors) have verified this. The E/M codes 99221-99223 (Initial Hospital Visit) may be used even though the admitting physician used them (with the modifier AI that you do not append). However, the POS is Inpatient Hospital — not office. This is an ongoing focus for RAC audits.

Q. For ROP exams, do you bill eye codes? And if so, do you bill comprehensive or intermediate exam?

By CPT definition, comprehensive eye code includes gross visual fields and basic sensorimotor exam. I am guessing you cannot do either of these, nor VA, on an infant. Can you still bill comprehensive, since the docs seem to do everything else that would comprise a comprehensive exam? Or do you bill E&M codes?

A. There is quite a bit that one can examine in an infant; however, the comprehensive eye examination (CPT codes 92004/92014) have the following mandatory elements: confrontation visual fields, sensorimotor evaluation, lids/adnexa and external examination, and ophthalmoscopy. I opine that on an infant, the intent of the extent of the required examination cannot be met. I advise using the appropriate E/M code and extended ophthalmoscopy – following all the requirements of that code. Please see the next two questions.

Q. We need some help!We billed an office visit, refraction and extended ophthalmoscopy to Medicare. Medicare is processing the office visit and refraction, but not the 92225, and said it was missing a modifier. My biller and I don’t know what modifier was missing. Thanks!

A. CPT code 92225 is for extended ophthalmoscopy and, in addition to being a physician service, it is designated as a unilateral diagnostic test by Medicare, meaning that you get paid at 100% of the allowable for each side. For the computer to process that data, you have to use a location modifier for each service — LT or RT for left or right, with a separate line entry for each side. As a side note, many MACs are requiring this type of identification for physician and ASC surgical coding claims.

Q. A retina specialist who treats patients in our officewants the scribe to draw the extended ophthalmoscopy. Is this permissible? Thanks in advance for your help!

A. Extended ophthalmoscopy is considered a physician service (as is gonioscopy) and has no separate professional and technical component. The drawing is physician’s work. It must be done by the physician.

Q. My physician is very thorough when seeing our patients and excellent at documenting what he does. He feels after reviewing the E/Mcodes, that he meets at least two out of three key components of an established patient, spends the required time with them and feels that CPT 99215 would be appropriate in many cases. How does Medicare feel about this complex code being used often? Thank you again for your feedback.

A. Using CPT code 99215 requires two out of three of the key components be at the same level. In retina coding, the key components should be examination and medical decision making. This means there must be medical necessity for performing all 14 elements (not just doing them to do them; and the physician must perform all 14), and the risk level for medical decision making must be high. That occurs in no more than probably 3% to 5% of established patient office visits in a typical retina practice. RP

CPT codes copyrighted 2012 by the American Medical Association.