Coding by Time in Ophthalmology

By George Mayo, MD

In ophthalmology we can code by standard evaluation and management codes (E/M), by eye codes, or by time. You should create a matrix for each payer showing whether you are reimbursed more for eye or E/M codes. This information can be obtained from each payer. For Medicare you can look it up on the Centers for Medicare and Medicare Services (www.cms.hhs.gov/PFSlookup/). If you choose to document by E/M code, then keep in mind the time requirement for each level of service (Table 1). If you fail to reach this time level, but meet the requisite history, exam and medical decision making elements then you can bill for the appropriate code. If, however, you do not meet the requisite history, exam and medical decision making elements but meet or exceed the time limits listed below then you can still bill for the code. For example, say you spend 45 minutes with a new patient. You have a detailed history and examination but medical decision making is of low complexity. By standard E/M coding, this would be 99203. According to time spent with the patient, you can code 99204 with substantially higher reimbursement.

What documentation do you need in the chart? You should document the amount of face to face time with patient. Also, if you do not meet the required history, exam and medical decision making elements, then to code by time, more than half of the time must be spent counseling or coordinating care for the patient. If you meet this requirement, then in this case you should document “45 minutes of face to face time with patient, > 50 % of time spent counseling or coordinating care.”

For cases in which you exceed the time allotted for a given E/M code by more then 30 minutes, you can append modifier 21, prolonged evaluation and management services, and then add code 99354 for outpatient time of 30 to 74 minutes and code 99355 for each additional 30 minutes (Table 2). This code can be billed up to four times. For inpatient time, use codes 99356 and 99357, respectively. For example, a new outpatient visit of 224 minutes, which meets the outlined requirements, would be billed as 99205-21, 99354, 99355, 99355.

The bottom line is that we work hard to care for our patients and preserve their vision. In order to keep doing what we do, we need adequate resources. So be sure to get the maximum reimbursement you are entitled to using the appropriate eye code, E/M code, or time based E/M code.

Table 1: Time requirements for E/M codes.

Table 2: Time requirements for Prolonged Services codes.

References

1. Current Procedural Terminology 2008. AMA CPT Advisory Committee. American Medical Association, Chicago, IL 2008.


2. http://www.cms.hhs.gov/. Centers for Medicare & Medicaid Services 2009.