Skip to main content
  • Savvy Coder

    Exams That Don’t Take Place in the Office (Tip: The New E/M Guidelines Don’t Apply)

    By Sue Vicchrilli, COT, OCS, OCSR, and Anthony P. Johnson, MD, FACS, OCS
    Add to My Bookmarks

    Download PDF

    Do you examine patients in locations other than the office? For those patients, don’t make the mistake of applying the 2021 eval­uation and management (E/M) rules that went into effect on Jan. 1. These new rules only apply to E/M services provided in the office.

    Exams in Nonoffice Facilities

    When the place of service (POS) is not an office, you should still use the 1997 E/M rules. POS codes for nonoffice facilities include the following:

    • POS 13: Assisted living facility
    • POS 21: Hospital inpatient service
    • POS 23: Emergency department
    • POS 31: Skilled nursing facility
    • POS 32: Nursing home

    How quickly will the 2021 office-based criteria be added to nonoffice locations? It may occur in 2023, although the American Medical Association is working to fast track the changes in 2022.

    Case Study: Preterm Infant

    The inpatient hospital exam is a frequent target of audits. It is therefore important to use the proper set of E/M guidelines and apply them correctly. Anthony P. Johnson, MD, FACS, OCS, provides the following example.

    Patient’s birth and initial NICU treatment. The patient was born by cesarean section at a gestational age of 27 weeks. He was the first born of twins and had a birth weight of 875 g.

    Until his preterm birth, his prenatal course had been normal. Prenatal ultra­sound did not show signs of abnormal development.

    However, cranial ultrasound iden­tified a grade I intraventricular hem­orrhage. He was treated for presumed sepsis at age 2 weeks. He also required a transfusion of packed red blood cells (10 mL/kg) at age 2 weeks. He needed ventilator support, and his oxygen sat­uration was difficult to control during the first 10 days, fluctuating between 84% and 96%.

    He was maintained on IV antibiotics for 10 days, and he was weaned from the ventilator after three weeks.

    ROP screening and ocular treat­ment. The patient’s initial ROP screen­ing at 31 weeks was significant for stage 2 zone I ROP in both eyes with plus disease in both eyes. The examination revealed intermittent fixing and follow­ing and a small angle exophoria. The pupillary examination was normal, though the pupils both reacted slug­gishly with subtle evidence of possibly mildly engorged iris vessels. There was no evidence of cataract formation. He was treated with intravitreal bevacizumab (Avastin) the same day as his ini­tial screening examination. He tolerated the procedure well.

    Follow-up was scheduled for four days later.

    Coding for ROP screening. Use POS code 21 to indicate that it was a hospital inpatient service. Next, choose from three CPT codes—99221, 99222, and 99223, which are used for initial hospi­tal care for problems that, typically, are of low, medium, and high risk, respec­tively.

    Although the above scenario could qualify as high risk, you can’t report CPT code 99223. To bill for that code, the patient visit should have included a comprehensive history and exam. Because those two elements weren’t performed, the appropriate code is 99221, according to the 1997 E/M documentation guidelines.

    E/M RESOURCES. Visit aao.org/em for Q&As, links to EyeNet’s four-part series, and more.

    Take the OCS Exam

    “The Ophthalmic Coding Specialist [OCS] exam is a way of demonstrating expertise in a standardized format,” said Dr. Johnson, who noted that claims payers have recognized his OCS credentials when he has com­municated with them. At his practice —Jervey Eye Group in Greenville, S.C.—he encourages staff to take the OCS and OCS Retina exams. Not only has the OCS process improved his practice’s accounts receivable, but also it provides extra credibility when dealing with insurance companies about disputed claims, he said.

    To get started, visit aao.org/ocs.