Ophthalmology and Optometry Coding Alert

Many ophthalmologists have a hard time with claims for A-scans with intraocular lens (IOL) implant power calculations, especially whenas is often the casethey have to be done more than once on the same patient. The problem is that many coders dont have any idea what Medicares payment policy is for A-scans with IOL calculations (76519), a service that must be done before cataract surgery.

And no wonder. It is one of the most confusing policies on Medicares books. In fact, A-scans are the only service in ophthalmology for which Medicare has determined two separate payment policiesone for the technical component, and one for the professional component. The code for the entire measurement and IOL calculation process, known commonly as an A-scan, is 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation). Lise Roberts, an ophthalmology coding and compliance consultant and vice president of Healthcare Compliance Strategies, based in Syosset, NY, explains how A-scan coding works.

Understanding Technical and Professional Components is Key

1. The technical component: The actual measuring of the eye is the technical portion of 76519. An A-scan is an ultrasonic instrument which measures the eye from the front of the cornea to the back of the retina. It measures the axial length of the eye. Keratometry, a separate procedure, measures the shape of the cornea. Virtually all ophthalmologists have equipment which automatically takes these two pieces of information and turns them into a calculation for the power of the intraocular lens implant. Medicare only allows the technical component to be billed once a year unless there is medical necessity to do it again in less than that time.

2. The professional component: Calculating and selecting the power of the IOL to implant is the professional portion of 76519. But there is not just one power that is calculated, Roberts explains. Instead, a range of powers is given that might be appropriate. The ophthalmologist selects the power that he or she wants to insert, based on various considerations, she says. Close to planoor perfect visionis not always the best, because the other eye may be very farsighted, for example. You dont want one eye to be totally out of sync with the other eye, Roberts notes. In addition to picking the power of the IOL, the ophthalmologist picks the style. The professional component can be billed for each cataract surgery regardless of the time interval between operations.

Medicares Payment Policies

Medicares policy defines the technical component as a bilateral code. In other words, Roberts explains, when you bill 76519, payment for the technical component for both eyes is included in the Medicare fee schedule. The professional component, however, is defined by a unilateral code. So the professional fee allowance for 76519 includes payment for only one eye. How many fees are listed in Medicares fee schedule? The answer is three:

1. 76519 with no modifier (which includes payment for a technical component for both eyes and a professional
component for one eye);
2. 76519-26 (includes payment for the professional
component for one eye), and;
3. 76519-TC (includes payment for the technical
component for both eyes).

Note: The -TC covers both eyes because the fellow eye is always measured to ensure the accuracy of the measurement of the eye to be operated on. Most people have a very small difference in the length of the two eyes, so you know your measurement is not far off if they both measure approximately the same. This is particularly important if the cataract is very dense, making accurate measurement difficult.

Coding Examples and Solutions

1. Scenario: A patient has cataracts in both eyes, but the ophthalmologist sees the right eye is much worse than the left. He says the right eye should be done first.

Coding Solution: 76519-RT. This includes payment for the technical component for both eyes, and professional component for the right eye.

Tip: Not all billers use the eye modifiers (the -RT or -LT) for this. But Roberts stresses its very useful later on, mostly because if something comes up in the other eye, Medicare can see that you are not duplicating a procedure or claim.

2. Scenario: Its six months later, and the ophthalmologist and patient are ready to remove the cataract in the left eye.

Coding Solution: This would be billed 76519-26-LT. The -26 modifier has the effect of subtracting the technical component of the service, so that only the calculation and the ophthalmologists determination of the IOL power and style for one eye would be reimbursed.

3. Scenario: This is a new patient, also with cataracts in both eyes. However, the cataract in the right eye is much worse than the one in the left, which is growing very slow. The right eye is done first, using 76519-RT as per scenario 1. The second eye doesnt need to be done for two years. Since more than a year has gone by, most ophthalmologists would perform another A-scan, to do the measurement again, as well as the IOL determination.

Coding Solution: This second A-scan will be billed 76519-LT (technical component for both eyes, and professional component for the left).

4. Scenario: This is yet another patient, who presents with bad cataracts in both eyes. The ophthalmologist and the patient agree both eyes will be done, the first immediately, and the second in two weeks. The ophthalmologist makes the selection of the IOL power for both implants at the same time.

Coding Solution: This would be at least a two-line entry on the claim. The first line would be 76519-TC (-TC signifies the technical component, which is automatically a bilateral payment), and 76519-26-50 (-26 signifies the professional component, which is unilateral, but -50 signifies bilateral, so the second line would reimburse for the professional component in both eyes, thus doubling the reimbursement of 76519-26). There are a few carriers who dont accept the -50 modifier, Roberts notes. For these, you would have to make a three-line entry on the claim form. On the first line, code 76519-TC, the second 76519-26-RT, and on the third put 76519-26-LT.

Determine Dates of Service

The fourth scenario is not that uncommon, coders report. We do this quite a bit, says Cassy Thrasher, head of billing and accounts receivable for Atlantic Ophthalmology of Beaufort, SC. But we dont use the same dates of service for both eyes, because Medicare kept saying it was a duplicate. Even though she used modifiers, Thrasher found that Medicare was not recognizing that two separate eyes were being done at the same time. We have many patients who get both eyes done within two to three weeks, she says. But we use the second date of service for the second professional component.

Using the surgery date as the second date is the most common way of solving this problem. Another is to do the opposite of what you were doing before, recommends Roberts. Lets say you were listing the professional components on one line-item with the -50 modifier. Instead, try listing it on two line-items with the -RT and
-LT, she says. And if you are using two line-items with the -RT and -LT, try one with the -50 modifier.

A-scans are such an integral part of an ophthalmologists practice that many coders worry about why the coding is so complicated. Dont worryit is complicated, but if you follow the rules, it works. The problem with not following the rules occurs when you bill 76519 (with no modifiers) more than once a year. If you happen to get paidand sometimes Medicares processing system does allow these to get throughand this happens more than once, then you have a repeated pattern, and Medicare can call that fraud in an investigation.