Ophthalmology and Optometry Coding Alert

And learn how to avoid them

Do your physicians know to accurately link the diagnoses listed on the encounter form with the proper procedure codes to support the services rendered? Not according to the most renowned experts in the ophthalmology-coding field.
 
We contacted claims processing personnel at health plans across the country, several coding and reimbursement consultants, and coders in the field to find out the most common errors ophthalmologists' offices make when submitting their claims.
 
Here are the top five sources of claims denials so you can avoid them:

1. Inaccurate Reporting of Diagnosis Codes

Incorrect linking. Payers and consultants alike outlined problems with the way practices reported ICD-9 codes and how physicians linked them with corresponding medical procedures.
 
A key issue is the failure to use specific diagnosis codes when they are available, says Catherine Brink, president of Healthcare Resource Management in Spring Lake, N.J.
 
Several coders have complained of rejections when they code 15823 (Blepharoplasty, upper eyelid; with excessive skin weighting down lid).
 
Medicare will often reject this as cosmetic surgery unless you tie it to an appropriate diagnosis code that proves medical necessity, such as 374.30 (Ptosis of eyelid, unspecified) and 374.34 (Blepharochalasis).
 
Misuse of the fifth digit. In many cases, coders also tend to leave off a necessary fifth digit in the ICD-9 code or, in at least a few cases, put on a fifth digit when none is necessary. The carrier will either downcode the claim or send it back to the provider for correction.
 
"Among the claims that we have to pull out and seek more information on, we see a lot of invalid diagnosis codes," says Diana Seymour, manager of front-end claims systems for Blue Cross Blue Shield of Arizona. "What we usually see is an extra zero at the end. What we are finding is that, if we drop the zero, the codes become valid."

2. Improperly Reporting Bilateral Services

Errors related to unilateral versus bilateral often cause claims processing problems, according to Michael Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J., and the problem isn't always the fault of the coder.
 
Reporting 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) is especially problematic, says Molly Cross, business operations manager at The Eye Centers of Racine & Kenosha in Wisconsin. "At times, they [carriers] will pay 92235 with modifier -50 (Bilateral procedure),"
Cross says.
 
"Sometimes they want to see two line items with separate eye modifiers. Even Medicare is inconsistent," Cross adds.

3. Alpha Modifier Misuse  
 
Misuse and nonuse of eye modifiers is another common problem almost all payers and consultants mentioned. Ophthalmologists often misuse the eye modifiers (-LT, Left side; and -RT, Right side). But these modifiers can be the key to ensuring proper reimbursement, especially when similar procedures are performed on both eyes.
 
For example, some offices report a procedure on one eye within the global period of the same procedure on the other eye with the same diagnosis and fail to add the modifier for the second eye. The eye modifier clearly shows why Medicare should reimburse you for the second procedure with no  reduction in fees.
 
If, during the postoperative period for cataract surgery on a patient's left eye (66830, Removal of secondary membraneous cataract [opacified posterior lens capsule and/or anterior hyaloid] with corneo-scleral section, with or without iridectomy [iridocapsulotomy, iridocapsulectomy]), the ophthalmologist notices that the right eye has developed a cataract also, report the surgery for the other eye using one of the eye modifiers.
 
Or if during the cataract surgery postoperative period for a patient's left eye, the ophthalmologist notices that the right eye - which had cataract surgery with an intraocular lens (IOL) a year ago - has developed a significantly cloudy posterior capsule that requires more surgery.
 
You should report the office visit (99211-99215) with modifiers -24 (Unrelated evaluation and management service by the same physician during a postoperative period) and -57 (Decision for surgery).
 
Append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) and modifier -RT to the surgical procedure code. You should also use the diagnosis code 366.53 (Cataract; after cataract; after-cataract, obscuring vision) to show medical necessity for the procedure.
 
Also, append modifiers -LT and -RT for any testing service if the insurance carrier does not recognize modifier -50, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and reimbursement consultancy. Then you have to use two lines with modifier -LT appended to the proper procedure code on one, and the same code with modifier -RT on the other.
 
If the payer recognizes a CPT code as a unilateral procedure (payable per eye) and accepts modifier -50 to show that it was performed bilaterally when billing on one line, your documentation must show that the diagnosis applies to both eyes. For example, if you report 92235 appended with modifier -50, make sure you document that it was bilateral.
 
Otherwise, you are submitting a fraudulent claim, Duran says. If the diagnosis is different, you should submit the same procedure code on separate lines with the documented diagnosis code attached to each line.
 
Without the eye modifiers, the payer will assume the procedure - except for lasers - is performed to treat a complication and will reduce the fee by the amount of the postoperative component of the global surgery package (usually 20 percent). If you perform the second procedure on the other eye, it is by definition unrelated, Duran says.

4. Overlooking Eyelid-Modifier Opportunities

Occasionally, the eyelid modifiers (-E1-E4) are preferable to modifiers -RT and -LT. For example, the ophthalmologist performs 67904 (Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) on both upper lids.
 
When performed bilaterally, you should use 67904-50 for Medicare, not the eye modifiers or the eyelid modifiers.
 
But for other payers, you should use the eyelid modifiers - for example, 67904-E1 and 67904-E3 for both upper lids. The eyelid modifiers are more specific than either 67904-50 or 67904-RT and 67904-LT.

5. Using Outdated Manuals

Use of outdated or deleted procedure codes is also a common error, says Sandy Brown, claims manager for Health Plus of Louisiana, a 35,000-member HMO in Shreveport.
 
Practices often submit codes that have been removed from CPT or they use specific codes in error, particularly age-specific codes, Seymour adds. "I think that's a problem for everybody."
 
For instance, coders with last year's CPT manual may continue to use the old Category III code 0025T instead of the new code 76514 (Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) to report pachymetry (see the following story on modifiers -26 and -TC).
 
Although buying new CPT and ICD-9 books may be too expensive for everyone in the practice each year, many practice managers and consultants advise to invest in a few new copies and store them in a central location and make sure that employees have access to them.