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Coding for Ocular Allergies
The usual suspects don't always fit the situation. Here are some coding tips.
BY PATRICIA J. KENNEDY,
C.O.M.T., C.O.E., C.P.C.
Evaluation and management (E/M) coding is complicated and frustrating for most clinicians. For this reason, many doctors are tempted to use the eye codes (920x2 & 920x4) exclusively because they're easier to document and tend to have more favorable reimbursement. However, the eye codes still have documentation requirements -- and they may not always fit when you're coding a visit from a patient with ocular allergies.
Coding for allergy exams
Different circumstances may call for different codes. Consider the following sections the next time you an allergy case enters the office.
Standard ocular allergy office visit. You can code many allergy-related office visits as intermediate eye exams (920x2). An intermediate eye exam "describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem," according to
CPT. Documentation must include a "history, general medical observation, external ocular and adnexal exam and other diagnostic procedures as indicated . . . ."
In the case of a patient presenting with allergy symptoms, the problem is likely to fall into one of three categories: Episodic (a "new recurrence"), exacerbated (an existing allergy that has become worse) or an altogether new problem. Any of these would satisfy the first requirement of an intermediate examination.
An interview regarding coincidental systemic allergies would satisfy the requirement for general medical observation. And standard practice in this situation is to examine the external segment of the eye, including the ocular
adnexa, which satisfies the third requirement.
Follow-up visit. If the patient returns for follow up, it's likely that the prescribed treatment has improved his symptoms. This pre-empts using an intermediate eye code because there's no new condition or management problem. Thus 99213 or 99212 are usually more appropriate for follow-up visits.
Unexpected complications. An allergy complaint may occasionally mask a more serious condition that requires a systemic or lab workup. In these cases, an intermediate eye exam wouldn't adequately reflect the level of service provided; in this case, a higher-level code is appropriate.
Referral. Sometimes an ocular allergy patient is referred for evaluation and treatment. Whether this qualifies as a consultation depends on the communication between the doctors. The referring doctor must be asking you for an opinion and suggestions regarding the course of treatment. (Who renders the treatment is immaterial.) The key is that the referring doctor is likely to use the information you provide.
You wouldn't, however, code a patient referred by an emergency room physician, for example, as a consultation because the referring doctor is extremely unlikely to continue care of the patient. This would be considered a transfer of care and an appropriate eye code or E/M code would apply.
Note: Because consultations are scored the same as new patient E/M visits, they're usually considered a relatively low level exam.
Coding allergic diseases
When you diagnose a disease based on patient complaints, use the disease as your principal ICD-9 code. Ocular allergies can be primary to the lids (e.g., 373.32 contact and allergic dermatitis of the eyelid) or the conjunctiva (e.g., 372.05 acute atopic conjunctivitis).
On the rare occasion that the patient's complaint doesn't lead you to a definitive diagnosis, use it as the primary diagnosis. As always, choose the most specific code that accurately represents the patient's condition.
MS. KENNEDY IS A SENIOR CONSULTANT WITH CORCORAN CONSULTING GROUP IN SAN
BERNADINO, CALIF. CONTACT THE COMPANY AT (800) 399-6565 OR VISIT WWW.CORCORANCCG.COM.
If you have a coding question you'd like
answered, send it to Ren� Luthe, c/o Optometric Management, 1300 Virginia
Drive, Suite 400, Ft. Washington, PA 19034. E-mail firstname.lastname@example.org.
Optometric Management, Issue: March 2003