Ophthalmology and Optometry Coding Alert

When YAG laser surgery (66821) is performed on a patient, and you see that patient within the 90-day post-operative period, how should you code so you can get paid for that post-op exam? The issue is raised by Jerry N. Kirby, MD, of Cincinnati, OH, who submitted a claim to Medicare for 66821. The surgery diagnosis was 366.53 (after-cataract, obscuring vision). Two months later the doctor performed an exam on the patient indicating a diagnosis of nuclear cataracts (366.04). Medicare will not pay for the exam because apparently the diagnosis codes are related, says Kirby. Is there any way the exam can be paid?

We talked to three billing experts for an answer, not only to the above scenario, but to related ones. They all agree that accurate diagnosis codes and modifiers are crucial in getting paid for that post-surgery office visit.

1. Different eye, same diagnosis. If the doctor is doing the exam and finds out he has to do a YAG laser on the other eye, he would use the same diagnosis code as for the initial surgery 366.53, says Melissa Tapley, office manager for Coastal Eye Care, a solo-provider in Blue Hill, ME. He should also use modifier -24 on the office visit, for an unrelated evaluation and management service by the same physician during a postoperative period. You also need the eye modifier: -LT (left) or -RT (right). But this will only work if the eye modifier (for the other eye) was used in the initial surgery. First you use the CPT code, then the -24 modifier, and then the eye modifier. So the office visit could, for example, be code 99212 -24-LT.

(Tip: Its a good idea to always use the eye modifier for surgery, even if you dont know what you will be doing for the patient in the future. This way, it allows you to use the eye modifiers later on.)

2. Different eye, different diagnosis. If the doctor finds a new cataract in the other eye, the diagnosis code should be 366.04 (Nuclear cataract, defect with the center of the lens), says Tapley. To get the office visit paid for in the exam, you need to use a modifier -24 on the E/M visit, she says. Note that the doctor couldnt find a diagnosis of 366.04 in the same eye that 66821 was performed on, says Tapley. The cataract was removed before the YAG laser, which was just to put a hole in the secondary membrane, she explains. You can only do a YAG laser once. One in four cataract surgery patients develop a haze in the secondary membrane after the artificial lens is put in; 66821 clears up this haze. Again, you also need the -LT or -RT modifiers.

3. Surgery same day as exam: modifiers. What if the doctor decides to do surgery on the same day as the exam? Lets say the different eye-same diagnosis scenario applies. If its discovered that the patient needs a YAG capsulotomy that day, you need to use modifier -79 (Unrelated procedure or service by the same physician during the post-op period) on the surgery, says Sally Ceravolo, head of accounts receivable at Barry Eye Care Center, a solo provider in Groton, CT. The eye modifier is crucial for both procedures here. So for a YAG capsulotomy on the right eye, done within the 90-day post-op period of the same procedure done on the left eye, you would code 66821-79-RT. The office visit would also need the -57 modifier, showing that you made the decision to do surgery during that visit. In some states (including virtually all of the Northeast), you will not get paid for the office visit done that day, unless the office visit is for an entirely different problem. But some carriers will pay; find out your carriers stance before billing.