Ophthalmology and Optometry Coding Alert

Knapp offers this advice: If you perform a bilateral A-scan, "make sure the second A-scan is always billed with the -26 modifier to Medicare, occasionally, if it is charged out with -LTor -RTor no modifier at all, Medicare will pay the same fee for the second scan as they did for the first, and you will need to refund the difference."

Suppose a Medicare patient undergoes an A-scan with IOLcalculation, with the cataract surgery planned for the right eye. You code 76519-RT. The first use of 76519 accounts for the technical component of both eyes (which is performed for comparison) and the professional component of the right eye. If and when cataract surgery is performed on the fellow eye, the physician typically uses the same ultrasound, compares the patient's visual outcome with the first IOLselection, and selects the IOL power for the fellow eye. "This is when a second service can be billed 76519-26-LT for the interpretation/professional component for the fellow eye," Duran says.

But suppose a physician feels that a new technical portion of the service, the A-scan itself, needs to be performed. For example, the physician performs an A-scan on a patient's right eye prior to performing cataract surgery. Fourteen months later, that same physician takes a second A-scan on that same patient's left eye prior to cataract surgery in the left eye. Depending on your locality and your Medicare carrier's frequency guideline, you may or may not be paid without going through the review process, Duran says.

"Some carriers have determined that it is medically necessary to repeat the scan after a year has passed, some carriers do not have a time limit, and one carrier states it's once per lifetime," she says. This does not mean that if you receive a denial you have to perform a write-off of the service, she notes, but you will have to prove why it was medically necessary to repeat the testing service in order to be paid. "Something people don't commonly know is that even when you send a claim into review that has been denied with proof of medical necessity, it may not have an effect on your claim."

Duran explains the system: At the first review process, it is the job of the reviewer to make sure the claim was processed correctly. If the local medical review policy states the service is to be paid only once per year, then the denial may be upheld. At the next step, the appeal process, you can request again that the claim be reprocessed for payment based on the information you have provided.

In the event that an A-scan is taken either unilaterally or bilaterally, but the professional component of the service is not performed (i.e., if the cataract surgery is cancelled and the IOLpower calculation is not performed), you may need to bill the technical component of an A-scan separately with 76519-TC.

Another example of when to use the -TC modifier with 76519 is if there is a cancellation or indefinite postponement of the surgery by the patient in advance, Knapp says.

Commercial carriers may vary on what billing method they will accept for 76519. Unlike Medicare carriers, some carriers will pay for 76519-RT followed by 76519-LT a few weeks later, without requiring you to use modifier -26, because they consider 76519 inherently unilateral. Don't make the mistake of only billing the professional component of 76519 assuming you have already been reimbursed for the technical component of 76519 for both eyes check the patient's insurance policy first.

Confusion still lingers about the supervision requirements for A-scans and B-scans, possibly a result of the 2001 CMS downgrade of the required level of supervision from personal to direct noted by Parker, and then the subsequent supervision-requirement downgrade from direct to general for three of the A-scan codes in April 2002.

Codes 76511-TC, 76512-TC and 76513-TC all require direct physician supervision, which means the physician must be present in the office suite and he must be available to offer guidance and direction if necessary during the service. But supervision requirements for codes 76516-TC, 76519-TC and 76529-TC have been further reduced from direct to general, which means the ophthalmologist does not have to be in the building during the procedure.

Direct supervision "doesn't mean the physicians just need to be reachable by phone, or at a nearby office location," says Shirley Fullerton, CMBS, CPC, CPC-H, practice management and coding specialist in Las Vegas. They must be in the suite of offices, just not necessarily in the room where the procedure or service is being rendered, she adds.

Prior to the changes in supervision requirements, A-scans and B-scans required that the physician be in the room during the entire duration of the procedure to meet the personal-physician-supervision conditions.