Ophthalmology and Optometry Coding Alert

When charging for fluorescein angiography (92235) and for fundus photography (92250), how should you code the claim if only one eye is done, versus if both eyes? Angie Lovett of Hart Ophthalmology Associates, in Murray, KY, we talked to Laurie Hegtvedt, insurance supervisor for North Iowa Eye Clinic, a five-ophthalmologist, one-optometrist practice in Mason City, IA, offers an answer to this question.

Most of the time, we do fluorescein angiography and fundus photography on both eyes, says Hegtvedt.

The insurance supervisor goes on to offer the following advice when billing these procedures:

1. Angiography Billing. For an angiogram (92235), Medicare and Medicaid do not interpret the code as covering both eyes. So we have to bill two units for two eyes, Hegtvedt says. This would be coded 92235 x 2. For non-Medicare and non-Medicaid patients, instead of using 92235 twice, you should use the -50 modifier (bilateral procedure), she says. If you use 92235-50, you will get paid twice.

Tip: Another option is to use modifiers -RT (right eye) and -LT (left eye) after the code. Your claim would look like 92235-RT on one line and 92235-LT right underneath. This makes it clear that you have done the procedure twice, but not twice on the same eye.

2. Coding for Fundus Photography. Medicare does interpret 92250 (fundus photography) as being bilateral, says Hegtvedt. So when we do this procedure on both eyes, the code 92250 provides us with reimbursement for both eyes, she notes. What if you only do one eye? Then we use 92250 with a modifier -52, she says. Modifier -52 is for reduced services, and is used when a service or procedure is partially reduced or eliminated at the physicians discretion (CPT 1999).

Tip: Most Medicare carriers consider the -52 modifier as an information modifier only, not a payment modifier. It does not affect the fee.

3. E/M services Code or Eye Code. If you are coding 92250 or 92235, you should use an office visit code when reporting them, and not an eye code, recommends Hegtvedt. Medicare will definitely deny the fundus photos with an eye code. Furthermore, she urges that a fourth-level visit be coded. We would use a 99214 for an established patient, or a 99204 for a new patient, she says. This is a pretty detailed visit, with these procedures.

Tip: It is very important that you be familiar with your carriers instructions on how to bill bilateral procedures. Various methods are determined by how the Medicare claims carriers processing system is set up on handling payments. For example, some Medicare carriers require the line-item entry with 2" in the unit field and the -50 modifier appended to the procedure code, while others require a two-line-item entry, with the -LT modifier on one procedure code and the -RT modifier on the other procedure code. In some cases, the same carrier will handle each state in a different manner.