Ophthalmology and Optometry Coding Alert

Watch out: Different payers may have markedly different rules for coding.

A-scan ultrasound biometry is one of the most common procedures performed in ophthalmology offices, but coding them can present you with some uncommon problems.

According to CPT, A-scans -- 76511, 76516, and 76519 -- are the shortened names for amplitude modulation scans, "one-dimensional ultrasonic measurement procedures," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City.

Ophthalmologists use 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only) to diagnose eye-related complications such as eye tumors, hemorrhages, retinal detachment, etc.

Physicians use 76516 (Ophthalmic biometry by ultrasound echography, A-scan) to measure the axial length of the eye in preparation for cataract surgery.

And 76519 (Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) allows ophthalmologists to determine the intraocular lens calculation prior to cataract surgery only.

Look for Unilateral A-Scans

Typically, most A-scans are performed bilaterally. However, circumstances may only require the physician to perform a unilateral scan.

Each A-scan code has separate requirements when billed bilaterally. For example, payers consider 76511 unilateral, requiring the use of modifiers LT/RT/50 (Left side/Right side/Bilateral procedure) or the units value of "2."

But 76516 is inherently bilateral, so you shouldn't append modifier 50 to it.

Beware: For CPT Code 76519, some payers (including Medicare) consider only the technical component bilateral whereas the professional component is unilateral.

Some non-Medicare payers, on the other hand, want you to bill globally and don't typically divide the professional and technical components, so you must determine which insurance company you are coding for and what its policy is for billing A-scans.

Medicare carriers for Part B services have published articles specifying their preference to report a bilateral service with a single line item with modifier 50 and one unit of service, whereas [some] non-Medicare payers prefer reporting bilateral services with two line items -- one with RT and one unit of service, and the second with LT and one unit of service.

Hint: When it comes to bilateral modifiers, "it seems that more and more payers are not recognizing them and specifically asking coders not to use them," says Lynn McCormick, CPC, coder for a practice in Las Vegas. You should check your individual payers' guidelines first, however.

Master 76519 for Medicare

Medicare's payment policy for 76519 is notoriously confusing. First, an ophthalmologist performs this procedure before cataract surgery. When you submit claims for ophthalmic biometry -- CPT codes 76516 and 76519 -- to carriers, you should document the presence of a cataract and your plan for removing it. Make sure there is a written order by the provider in the patient's chart for the A-scan.

Clearly convey to the payer -- especially if the carrier is Medicare, which only covers 76519 when it is performed in conjunction with cataract surgery -- that the A-scan was performed with the intention of performing cataract surgery.

Billing myth: You must bill 76519 using the date the surgical procedure (typically 66984, Extracapsular cataract removal ...) is performed, and if the surgery doesn't take place, the test isn't billable. In the early 1990s, some carriers did want the billing date for the A-scan to be the same date as the cataract procedure; this is no longer true. "Billing for the A-Scan should be submitted with the actual date the service was performed," says Mac.

If the ophthalmologist does not perform the surgical procedure the test is still billable based on medical necessity (diagnosis coding of a cataract).

Bisect Technical and Professional Components

Second, you must split up the technical and professional components for 76519. Medicare breaks down 76519 into technical and professional components. The technical portion, represented by modifier TC (Technical component), is the actual measuring or performance of the test to take the measurements.

Special equipment takes two measurements -- the axial length of the eye and the shape of the cornea -- and turns them into a calculation for the power of the intraocular lens implant. The professional component, represented by modifier 26 (Professional component only), is for the provider's interpretation and selection of correct lens type and power for the lens implant.

Medicare considers the performance of the technical component of the A-scan to be inherently bilateral, so you should only report the technical component once, even when it is performed on both eyes prior to surgery for one eye.

The professional component (or interpretation), on the other hand, is considered "unilateral" and the physician's work for interpreting the test results is paid separately for each eye, therefore, you should report it for each eye when performed bilaterally.

The typical billing scenario for a surgeon who is considering surgery on both eyes is:

• 76519-RT; and
• 76519-LT-26.

"Payment for the above billing would include both the technical and professional components of the A-scan performed on both eyes," says Mac. "76519-RT pays for the technical component of both eyes and the professional component of the right eye and 76519-LT-26 pays for the professional component of the left eye."

Combat Payer Discrepancies With Knowledge

Payers often question medical necessity. Your local payer determines how often it will reimburse for 76519, both the technical and professional component -- and this payment frequency may differ from the above example.

Keep in mind that when a payer makes a frequency-ofpayment decision, they have based "frequency" on how often they think the service should be medically necessary, particularly if the service needs to be repeated within six months to a year of a previous A-scan, says Mac. If you have a circumstance that differs from the "norm," you can go through the appeals process, prove medical necessity, and request reconsideration for payment. Documentation to support the medical need to repeat an A-Scan will be mandatory in supporting your appeal.

Carriers' policies can differ greatly. One strategy is to set up a meeting with all of your carriers to review how they want A-scans billed in order to clear up inconsistencies among carriers.