Ophthalmology and Optometry Coding Alert

If your ophthalmologists are using scanning laser glaucoma testing (SLGT) for early detection of eye disease, you've probably found that getting proper reimbursement for this newer technology is a challenge.

Take a look at these expert answers to ensure you're up to speed on how to avoid three most-common SLGT coding pitfalls:

Answer: There are several technologies that the ophthalmologist may use to get diagnostic images through SLGTs. The trick is that you should not base your coding on the type of SLGT you use.

CPT has one code to describe all SLGTs: 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser] with interpretation and report, unilateral). You would report this code for any scanning laser testing.

Answer: CMS divides the relative value units (RVUs) for CPT 92135 into a technical component and a professional component. Therefore, you'll need to append a modifier, depending on which portion of the test you perform.

How it works: If your ophthalmologist performs only the test (technical component) and does not read the results, you should report 92135-TC (Technical . component). If another office performs the technical component, however, and you do the interpretation and report, you should append modifier 26 (Professional component) to 92135.

Exception: Did the patient have the test performed by another physician who already performed and billed for both the technical and professional components? If that patient is now seeing your physician and presents with those medical records from the other practice, the above rule does not apply, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, director of Best Practices-Network Operations at Mount Sinai Hospital in New York City.

Bill for the professional component only if an agreed billing arrangement is in place where the test is performed elsewhere and your physician is performing the professional reading with documentation of the interpretation and report. "Each party bills for its respective work process (technical [TC] or professional [26])," explains Mac.

Example: As the first ophthalmologist in your area to buy SLGT equipment, your physician offers to do the test for other interested doctors on a referral basis. If the ophthalmologist performs the evaluation for another doctor, then you would file 92135-TC only and let the referring doctor perform and file the 92135-26 portion, says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

"Assuming you as the tester may view and understand the results better than the referring doctor, you still wouldn't file the 26 portion even if you discussed the results with the interpreting doctor," Gibson says. "You both can't file the 26 portion; only one TC portion and one26 portion is allowed per test."

This scenario works in reverse if someone else has an SLGT -- also known as optical coherence tomography (OCT) or glaucoma diagnosis (GDx) -- and your office sends patients there for an evaluation, Gibson notes. You file the 92135-26 portion and prepare the interpretation and report.

Answer: Medicare considers 92135 to be inherently unilateral, meaning that the RVUs in the Fee Schedule represent the work done on only one eye. If your ophthalmologist performs an SLGT on only one eye, report one unit of 92135 and append the body side modifier RT (Right side) or LT (Left side) to indicate which eye your doc tested.

Carriers differ on how you should report a scanning laser test on both eyes. Medicare and many private carriers look for 92135 reported on two lines of the billing form, each with a "1" in the unit field and with the LT and RT modifiers appended. On the other hand, some carriers may want you to report one unit of 92135 with modifier 50 (Bilateral procedure) appended.

Another option is to append modifier 50 with a unit of 2 to bill for two eyes, says Kennard Singh, CPC, CCS-P, CHCO, from the SUNY College of Optometry in New York, N.Y. For some Medicare carriers, that is the correct coding. For example, Palmetto GBA specifies that to receive full bilateral reimbursement for all codes that, like 92135, are marked with bilateral indicator "3" in the Medicare Physician Fee Schedule, "the days/units (quantity billed) field must reflect '2' even when submitting CPT Modifier 50 or when submitting HCPCS modifiers RT and LT on the same detail line."

However: Some carriers disagree. For example, WPS Medicare, the Part B carrier for Illinois, Michigan, Minnesota, and Wisconsin, says, "An indicator of '3' indicates the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with a modifier 50 and a '1' in the units field, or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a '2' in the units field), allowed amount is based on 100 percent of the Medicare Fee Schedule for each side."

CMS indicates that this service should be paid at 100 percent for each eye and no bilateral reduction in payment should be made, says Mac. Therefore, it would be most appropriate to report 92135-RT and 92135-LT on separate lines of your claim form in order to present a clear, clean claim for reimbursement.

Bottom line: Check your local carrier for its preference. There is no modifier 50 policy that applies to all Medicare carriers.