Ophthalmology and Optometry Coding Alert

Incomplete procedures have different billing rules for ambulatory surgical centers (ASCs) than for the physicians operating in them. The ophthalmologist may not be able to bill for a planned procedure, but the ASC can, under certain circumstances. In general, the ASC can bill for at least a portion of the planned procedure, but not always.

Neither ASC nor physician can bill. For example, a patient is scheduled for cataract surgery. Prior to the patient being prepped and draped and starting sedation, the anesthesiologist finds out the patient has a bad cold, and the cataract surgery is cancelled. Neither the ASC nor the ophthalmologist can bill anything for this case.

ASC can bill part, physician cannot bill. If the patient is prepped and draped, and anesthesia has begun, but the surgery has to be stopped, the ASC will be able to bill for at least 25 percent of the fee.

For example, if the anesthesiologist detects a serious irregular heartbeat a few minutes into sedation and says the ophthalmologist cannot do the surgery, and the surgery is delayed at that point, the ASC can bill at least 25 percent. The ophthalmologist cannot bill.

ASC can bill part, physician can bill part. Some-times the procedure starts well, but must be stopped in the middle because, for example, the patient starts coughing and it cant be stopped. If the procedure was at midpoint when it stopped, the ASC could bill at least 50 percent. The ophthalmologist could bill if the portion of the procedure completed could be identified by a CPT code. If it couldnt, the physician would submit a billing with the intended CPT code, with modifier -53 (discontinued procedure). This also requires submission of the operative report. You should include a brief note detailing the percentage of the intraoperative work completed and what the period of anticipated postoperative care will be, which will assist the carrier when it attempts to price your claim. 

If the procedure had to be stopped without completing it just before closing, the ASC could bill at least 75 percent, and the ophthalmologist could bill as above, with modifier -53, and the operative report.

When billing for a terminated procedure in an ASC, the patients record must include 1) the reason for termination of the surgery, 2) services actually performed prior to termination and 3) supplies used prior to termination. Modifier -73 indicates a procedure terminated prior to anesthesia. Modifier -74 indicates a procedure terminated after administration of anesthesia.