Ophthalmology and Optometry Coding Alert

A-scans are some 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 A-mode scans, "one-dimensional ultrasonic measurement procedures." Ophthalmologists use 76511 (Ophthalmic ultrasound, diagnostic; quantitative Ascan only) to diagnose eye-related complications such as eye tumors, hemorrhages, and retinal detachment.

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.

"Typically, most A-scans are performed bilaterally," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. "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 unit 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," says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

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 Ascan to be the same date as the cataract procedure; this is no longer true.

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

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.

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 ultrasound itself (the technical component) bilateral, so you should only report it once, even when it is performed on both eyes prior to surgery. The professional component (or interpretation), on the other hand, is "unilateral" and you should report it for each eye when it is performed bilaterally. So, "if the surgeon is considering surgery on both eyes, you would bill 76519-RT and 76519-LT-26," says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. The Medicare carrier in his area limits 76519-TC to once per year, he notes.

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 frequencyof-payment decision, they have based "frequency" on how often they think the service should be medically necessary. 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. 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.

Remember: Codes 76511-TC, 76512-TC, and 76513-TC (Ophthalmic ultrasound, diagnostic ...) all require direct provider supervision, which means the ordering physician, or a physician member of the group practice, must be present in the office suite and he must be available to offer guidance and direction if needed during the service.

Direct supervision means the ophthalmologist must be in the suite of offices, just not necessarily in the room where the procedure is being rendered.

Code 76519-TC requires general supervision, which means there must be an order in the medical record for the procedure. However, a physician is not required to be present or available during the procedure.