coding & reimbursement
Coding for Ocular Allergies
The easy code isn't always the right choice. An expert helps clear the air.
By Patricia J. Kennedy, COMT, COE, CPC

Evaluation and management (E&M) coding is complicated and frustrating for most clinicians. For that reason, many doctors are tempted to use the eye codes (920x2 & 920x4) exclusively; they're easier to document and tend to have more favorable reimbursement. However, even when using the eye codes you must still meet documentation requirements -- and these codes may or may not be appropriate when treating a patient with ocular allergies.

Coding Allergy Exams

Different circumstances may call for different codes:

Standard ocular allergy office visit. Many allergy-related office visits can be coded 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." Docu mentation must include a "history, general medical observation, external ocular and adnexal examination 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's become worse), or an altogether new problem. Any of these would satisfy the first requirement of an intermediate exam. An interview regarding coincidental systemic allergies would satisfy the requirement for general medical observation. And, of course, 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 you have the patient return for follow-up, it's likely that the prescribed treatment will have improved the patient's signs and symptoms. This pre-empts using an intermediate eye code because there's no new condition or management problem. For that reason, 99213 or 99212 are usually more appropriate for follow-up visits.

Unexpected complications. On rare occasions, an allergy complaint may be masking a much more serious condition that may require a systemic or lab workup. In these cases, an intermediate eye exam wouldn't adequately reflect the level of service provided, and a higher-level code would be appropriate.

Referral. Sometimes an ocular allergy patient is referred in 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.

For example: A primary care physician (PCP) refers a patient to you for an evaluation of red, uncomfortable eyes. The PCP is following the patient for rheumatoid arthritis and knows that these patients are prone to eye disease. Because the PCP is caring for this patient on an ongoing basis, he or she will be interested in your opinion and suggestions, qualifying this as a consultation.

On the other hand, a patient referred by an emergency room physician wouldn't be coded as a consultation because the referring doctor is 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, the consult is likely to be considered a relatively low-level exam.

Diagnosis Codes

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 (i.e., 373.32, contact and allergic dermatitis of the eyelid) or the conjunctiva (i.e., 372.05, acute atopic conjunctivitis).

On the rare occasion that the patient's complaint doesn't lead you to a definitive diagnosis, use the patient's complaint as the primary diagnosis. As always, choose the most specific code that accurately represents the patient's condition.

Patricia J. Kennedy is a senior consultant with Corcoran Consulting Group in San Bernardino, Calif.