Ophthalmology and Optometry Coding Alert

Confusion about coding 67820 and 67825 can be a thing of the past if you can keep up with these modifiers

Epilation for trichiasis -- the removal of uncomfortable misdirected eyelashes that grow in toward the eyeball -- can be a difficult procedure to code because different carriers demand different methods of billing. Coding epilation becomes even more daunting if your ophthalmologist completes the procedure bilaterally or on multiple eyelids, or if more than one eyelash is removed.

The first step to correct coding is to determine your payer's accepted billing method. There are three methods of coding epilation -- per eye, per eyelid and per lash -- and your payer will only reimburse you for claims submitted by one of these methods.

Typically, private payers consider billing per eye to be the correct way to handle epilation coding. Some Medicare carriers may pay by the eyelid. Trailblazer of Texas, Maryland, Delaware, Virginia and Washington, D.C., on the other hand, considers 67820 (Correction of trichiasis; epilation, by forceps only) to be a bilateral procedure -- they'll pay the same whether the doctor performs the procedure on one eye or both eyes -- but allows billing of 67825 (... epilation by other than forceps [e.g., by electro-surgery, cryotherapy, laser surgery]) up to twice per eye. You may even come across a carrier with a policy that permits billing per lash.

Don't Forget the Exam

If your ophthalmologist examines the eye to find the rogue eyelash, you may be entitled to reimbursement for E/M services, says Vicky Phillips, billing coordinator for Nashville Vision Associates. "Normally, if a person comes in with a complaint," Phillips says, "we'll do a level-two or -three [E/M code], depending on how extensive the exam is, and add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)."

What to do: Link the E/M service to ICD-9 code 379.91 (Unspecified disorder of eye and adnexa; pain in or around eye), Phillips says. Then, if the ophthalmologist performs epilation to correct the problem, you can also code according to one of the three methods below.

Method 1: Code per Eye

If the carrier pays per eye, you should use the correct epilation code, 67820 or 67825, with the appropriate eye modifier, -RT or -LT, or modifier -50 (Bilateral procedure) if performed on both eyes.

Jackie Rice, accounting and insurance manager for The Eye Specialists in Virginia Beach, Va., codes per eye regardless of the carrier. If carriers reject claims, "We'll go back to them with more information," she says. "Usually, we don't have a problem."

For example, your carrier has a local medical review policy that allows billing by eye, and your ophthalmologist, by use of forceps, removes one lash from a patient's left lower eyelid and two lashes from the same patient's right upper eyelid. You should code 67820-50 if the carrier is Medicare, and 67820-LT, 67820-RT for private carriers.

Note: Some carriers that only pay per eye also require you to report the appropriate lid modifiers.

Method 2: Code per Eyelid

If you are submitting a claim to a carrier that permits billing by eyelid, you have twice as many modifiers (and twice the number of reimbursement possibilities) than when billing epilation per eye. Coding per eyelid is the method used most often by Regail Watson, office manager for Norfolk Eye Physicians and Surgeons in Norfolk, Va. Watson says, however, that the coding "depends on the carrier" -- some of her insurers prefer coding per eye or per lash.

The eyelid modifiers you should use to code per eyelid are -E1 (Upper left, eyelid), -E2 (Lower left, eyelid), -E3 (Upper right, eyelid) and -E4 (Lower right, eyelid).

Example: A patient presents with trichiasis of two lashes of her upper left eyelid, one lash of her lower left eyelid, and one lash of her lower right eyelid. The severity of the irritation to the patient's eyes constitutes medical necessity for removing the lashes. The ophthalmologist performs epilation of all the lashes. The procedures should be coded 67825-E1, 67825-51-E2, 67825-51-E4.

The multiple-procedures modifier -51 is used here to indicate that lashes were removed from multiple eyelids. As for payment, you are allowed the full fee for the first line billed, and 50 percent of the fee schedule for the second and third lines billed -- more than if you use CPT's coding-per-lash guidelines.

Method 3: Code per Lash

On the rare occasion when your carrier's epilation LMRP allows you to code by lash, use your knowledge of the local lash modifiers to wow your fellow coders. The lash modifiers begin with -Y2 for the first lash removed and continue to -Y9 for the eighth. For lashes nine and 10, use -Z2 and -Z3 respectively. You should then append modifier -99-U2 for the 11th lash as well as any additional lashes (-99, Multiple modifiers).

Don't Flinch While Facing Denials

If your carrier denies your initial claim for treatment of trichiasis, determine the exact reason for the denial, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding and reimbursement consultancy. "It may be necessary to contact a representative to get more specific information on the reason for denial," Duran says. "You might also be able to solicit assistance from your provider representative for managed-care plans and third-party plans."

Try this: Ask for assistance in submitting claims for multiple eyelash removal or modifier usage as necessary to obtain correct reimbursement for the work performed, Duran says. A letter describing the services provided attached to the claim resubmitted for review of correct payment may be your only recourse if you are unable to obtain provider assistance by telephone. Keep notes for future reference in filing similar claims to the carrier, Duran says.