Ophthalmology and Optometry Coding Alert

When billing for a YAG capsulotomy (66821) during the postoperative period of cataract surgery done on the same eye, would you use modifier -79 or -58?, asks Tracy Duffy, billing manager for the Eye Center at Memorial, a six-ophthalmologist practice in Albany, NY. And then, if a YAG capsulotomy had to be done twice on the same operative eye after cataract surgery during the postoperative period, would you use -79, then -78, or would you use -58 for both?

The answer to the modifier question depends partly on the circumstances. We talked to two practices: One would use -78 (return to OR for related procedure during postoperative period), and one would use -79 (unrelated procedure or service by same physician during the postoperative period). But each had reasons for making the choice of modifier. And both agree that getting paid for the second 66821 during the postoperative period is difficult.

The postoperative period for this procedure is 90 days, and the fee for the cataract surgery is supposed to cover all care related to the surgery provided by the operating physician during that time period. Of course, there are often situations which arise, such as the YAG capsulotomy, which need to be performed and which ophthalmologists believe they should be paid for. Thats what modifiers are for. The question is, which modifier should you use? And bear in mind that the medical record must reflect patient complaint and medical justification for the capsulotomy in order to get reimbursed, no matter. Some Medicare carriers are even requiring explanations of the medical necessity (including a patient complaint of difficulty seeing, which is not correctable by refraction) when the capsulotomy is performed within 90 days of cataract surgery on the same eye.

Modifier -58

Modifier -58 (staged or related procedure or service by same physician during postoperative period) should not be used in this case, says Lise Roberts, a billing and reimbursement consultant, who specializes in ophthalmology, and vice president of Health Care Compliance Strategies, Inc., based in Syosset, NY. The Health Care Financing Administration (HCFA) expressly prohibits using the -58 modifier with any of the laser codes for ophthalmology, Roberts explains. This is because all of the ophthalmology laser codes are described in CPT as being done in one or more sessions/stages. This supersedes the use of the -58 modifier, she states. HCFA has determined that one or more sessions/stages means that the original fee paid for the procedure includes any additional laser procedures of the same type on the same eye for a 90-day period after the first laser procedure. In general, modifier -58 should not be used in cases such as this, but there are rare circumstances that warrant its use (see section on related procedures on page 43).

The -78/-79 Mess

Candace Simerson, COA, administrator of Eye Physicians and Surgeons, a 10-provider practice based in Edina, MN, submits a claim to Medicare for a YAG capsulotomy done during the postoperative period with a modifier -79. If we use modifier -78, they wont pay at all, she says. But is that correct for the Medicare carrier to do? HCFA has a policy that when laser capsulotomy is performed within 90 days of cataract surgery on the same eye, the two procedures are related and that the cloudy capsule is a complication of the cataract surgery, relates Roberts. HCFA took this position specifically because it maintained that laser capsulotomy performed so quickly after cataract surgery should not be paid the full Medicare Fee Schedule, she states.

The -78 modifier correctly reduces the payment by the portion of the Medicare Fee Schedule that is for additional postoperative care. Further, HCFA defines modifier -78 as being specifically for a return to the operating room for a related procedure during the postoperative period. In May of 1993, Roberts explains, HCFA issued a clarification of its definition of an operating room, and has not changed it since then. The definition includes a hospital OR, ambulatory surgery center, laser room in an office, or endoscopy suite in an office. Simersons Medicare carrier has inappropriately set a computer screen denial on the modifier -78 when the place of service is the office, and since her ophthalmologists are not going to the operating room, they cant use modifier -78 properly and get paid, so what can she do?

Even with the -79 modifier, however, the ophthalmology billers have challenges, says Simerson. If the doctor performs a YAG in the postop period, first we bill it to Medicare with the -79 modifier, she says. Then we get the denial back. And then we send it in again with a medical necessity note from the doctor. Unfortunately, says Simerson, this is the only way her Medicare carrier will pay for the procedure.

Note: Make sure you check with your local Medicare carrier for their requirements.

Furthermore, if the YAG capsulotomy is done within the first 30 days of the postoperative period, this would raise the ante considerably, says Simerson. Our Medicare carrier would want to talk to the doctor before paying for it, because the procedure is performed so soon after the cataract surgery, the administrator explains.

What can be done to resolve this mess so that the Medicare carrier can process the claims correctly and smoothly without all the additional costs associated with their current procedure? Any practice that sees a consistent, inappropriate denial for a service by their Medicare carrier may contact their State Ophthalmology Societys Third Party Payer Liaison Committee, suggests Roberts. It appears in this case that Minnesotas Medicare carrier is attempting to curtail medically unnecessary laser capsulotomies through the denial of the -78 modified procedures and subsequent requirements for documentation, Roberts says. A better way to handle this issue, both for the Medicare carrier and the office, would be to establish a local medical policy in cooperation with the State Ophthalmology Society on the medical necessity criteria which could be reflected in the note/comment field for electronic claim submission. The State Ophthalmology Society could send a fax bulletin describing the medical policy and use of the -78 modifier to all its members. The Medicare carrier could also post the new medical policy on their Web site for all providers to have available, concludes Roberts.

Modifiers -58, -78 and -79 Defined Modifier -58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period. The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier -58 to the staged or related procedure. Modifier -78: Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier -78 to the related procedure. Modifier -79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier -79.

Are the Two Procedures Related?

There is also the question of whether the YAG capsulo-tomy is related or unrelated to the cataract surgery, and whether the repeated YAG capsulotomy is related to the first. Our sources agree that in all probability, these procedures are indeed related. The YAG laser is related to the cataract surgery, says Simerson. This means that modifier -58 could be used for the first YAG capsulotomy if the reason for the surgery was one of the following: The YAG was planned at the time of the cataract surgery because of a preexisting condition of the capsule (this is known as staging and must be reflected in the pre-op conditions listed in the operative note); the YAG capsulotomy was more extensive than the cataract surgery (highly unlikely, our sources say); or the YAG is being done as treatment for something discovered during a diagnostic surgical procedure (cataract surgery is therapeutic, not diagnostic).

Maura Ann Alarcon, office administrator for Jacob S. Plotkin, MD, of Brownsville, TX, would use modifier -78 for the 66821. The carrier would reduce the fee on the 66821 because of this modifier, says Alarcon. But it is related (the YAG and the cataract surgeries) and it is a return to the OR.

What about modifier -58? Alarcon doesnt think this would be appropriate unless, as stated above, the procedure was planned prospectively, was more extensive than the cataract surgery, or was being done as a treatment after diagnostic surgery.

Even for the modifier -78, Alarcon says, her Medicare carrier wants to see operative notes, at the very least.