Consultation within a group practice

Physicians must learn to combine visits rather than bill separately.

An established patient with your group practice is seen by a comprehensive ophthalmologist and later the same day is also seen by the retina specialist in your group. The comprehensive ophthalmologist identified extensive lattice degeneration as well as high myopia; he requested a consultation with the retina specialist because the patient is at high risk of retinal detachment. During the fundus exam, the retina specialist identified a peripheral retinal tear. Photocoagulation of the retinal tear was performed later the same day.

How should the two office visits be billed? What about the laser on the same day?

The MCPM Chapter 12, §30.6, contains instructions concerning evaluation and management services, codes 99201 to 99499, published in January 2001. Because consultations are considered an evaluation and management service, these revisions apply to them. The revision affects intraoffice consultations performed on the same day as an evaluation by another group member of the same specialty. The regulation reads:

“30.6.5. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.”

Because Medicare makes no distinction between subspecialties within ophthalmology, the comprehensive ophthalmologist and the retina specialist should bill for a service that represents the combined visits. If we assume that the first doctor performed a comprehensive eye exam (ie, CPT 92014 and 2.54 RVUs) and the second doctor performed a level two (expanded problem focused) outpatient consultation (ie, CPT 99242 and 2.43 RVUs), then the charge should reflect 4.97 RVUs that is closest to the value assigned to 99244 (comprehensive outpatient consultation). Note that modifier -57 must be amended to this code so that it can be reimbursed on the same day as the laser surgery (ie, CPT 67145).

Medicare considers optometry and ophthalmology to be different specialties. Therefore, if the request for a consultation in our example came from Dr. Optometrist in the group practice, then both exams would be reimbursed. The regulation includes a specific instruction to that effect in the last sentence.

Likewise, if the exams were performed on different days, without regard to specialty, then each eye exam would be billed individually, although the value to the practice would be nearly the same.

To continue the example, several months later the retina specialist sees this patient again to re-examine the eye that he treated for retinal tear as well as the long-standing lattice degeneration and high myopia. The retina specialist has a difficult time seeing the retina due to the presence of cataract. The comprehensive ophthalmologist sees the patient on the same day to evaluate the cataracts and to consider possible cataract surgery. These two examinations on the same day are performed for unrelated reasons so both exams may be separately reimbursed.

While this discussion highlights Medicare’s rule about combining visits, there is another point that merits some commentary. Within a group practice, the medical chart is shared. So when two doctors see the same patient within a short time interval of one another, a question is raised about the need to repeat every aspect of the initial eye exam. For instance, is it medically necessary for both doctors to measure IOP or assess confrontation visual fields? Without making too fine a point, the second doctor may reasonably accept some of the findings in the chart from his partner and perform again those parts of the exam that are necessary for his own interest in the case. From this concept we can reasonably say that two comprehensive eye exams on the same day for the same patient within a group practice are exceedingly unlikely to be necessary. Rather, the sum of the two exams will equal a single high-level service.

In another part of Medicare’s regulations (NCD §10.1.A), this last point is made explicit for the exam leading up to cataract surgery.

“Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan.”