Coding for group practices

November 15, 2007

Understanding the coding-related guidelines that govern collaborations in group practices will lead to appropriate payment. Generally, payers reimburse for one evaluation and management service per day per specialty in the same group practice. It is obvious, however, that two (or more) specialists within ophthalmology could serve legitimate roles in the same-day care of a patient. The existence of unrelated problems is the key to receiving payment for two same-day evaluations and management visits. More practice resources may be required to ensure proper payment.

Key Points

Generally, payers reimburse for one evaluation and management service per day per specialty in the same group practice. Frequently, payers do not recognize physician subspecialties (especially within ophthalmology). Therefore, only one office visit performed by different ophthalmologists in the same group typically is payable.

The payers' rationale for this practice is easy to comprehend. A potential for abuse arises when a patient presents to a group practice. Several providers in the practice could, in principle, see the patient for essentially the same problem and bill the insurance company multiple times for unnecessary services. An easy way to block this activity is to deny all but one of the encounters provided by the "equivalent" specialists.

This statement means that the existence of unrelated problems is the key to receiving payment for two same-day evaluations and management (or "eye code") visits. One clue to the payer that visits are for unrelated problems is the presence of two different ICD-9 diagnosis codes. (As suggested in the carrier's manual, the use of different diagnosis codes also is the mechanism by which office visits by the same provider, at different times during the day, are paid.)

Because optometrists have a specialty designation that differs from that of ophthalmologists, no special requirements exist before same-day. Same-practice office visits of an optometrist and ophthalmologist are paid.

It is common in group practice for two ophthalmic subspecialists (or a general ophthalmologist and a subspecialist) to see a patient on the same day. Sometimes the visits are for the same or a closely related problem, and sometimes they are for unrelated problems. Recall that subspecialists within ophthalmology are not generally considered to practice separate specialties.

If the requirements for a consultation are met, then payment for both encounters should follow (see "Consultative services carry high values, but rules are changing," Ophthalmology Times, April 15, 2006, or online at http://www.ophthalmologytimes.com/). Payers understand that a consultant often sees a patient on the same day and has another provider of the same specialty. Different diagnoses for the two providers should not be necessary. Among other things, though, it is essential that the consulting physician possess greater expertise in the area in question than does the physician that generated the request for a consultation.

The situation changes if neither visit is coded as a consultation. In this situation, the different diagnosis codes will be an important aid to payment. You may consider appending the –25 modifier to one of the office visits to lessen the chance of a denial. The –25 modifier designates a "significant, separately identifiable evaluation and management service" on the same day as another service. The full descriptor mentions that the "same physician" is rendering the two services. Because the two ophthalmologists are members of the same group, they may be considered the "same physician." Therefore, the modifier is relevant.

If the services of the two ophthalmologists are reasonable and necessary given the patient's condition, then you should pursue payment for both visits. If one of the visits is denied, then an appeal should be filed.