Ophthalmology and Optometry Coding Alert

When CCI 6.3 implemented the massive bundling edits last fall, ophthalmology coders wondered when they could bill A-scans with office visits. When HCFA rescinded the edits temporarily in February, the agency indicated it would educate the providers about the meaning of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and what constitutes a significant and separately identifiable service before reinstituting the edits. So far, nothing official has come from HCFA or the carriers.

The main bundles that affected ophthalmologists were E/M services and eye exams with A-scans and B-scans (76506-76536).

Most of the time, the ophthalmologist performs a significant and separately identifiable service when seeing the patient the same day that an A-scan is done. If you examine the structure of the eye, perhaps to determine the need for surgery, and then have your office staff perform an A-scan, you should bill the E/M service with modifier
-25, and the A-scan, says Michael X. Repka, MD, the American Academy of Ophthalmologys advisor to the AMA CPT Advisory Committee: If you are making a decision to do surgery that day, bill for the A-scan and the office visit.

If, however, the purpose of the patients visit is to measure the axial length, and the physician has made the code. Work described that is not designated by the code will likely have to be defended as representing complicated surgery. Remember that treatment must be reasonable and necessary to be valid, not experimental (non-FDA-approved off-label uses), Roberts says.

Unbundling

The AAO and the American Society of Cataract & Refractive Surgery (ASCRS) are working out exactly what 66982 can and, more important, cant be used for. In the meantime, if you are billing Medicare and your carrier is BC Kansas, you have a local medical review policy (LMRP) that tells you how to use the code. And if you dont have an LMRP, you have CPT.

Most ophthalmologists have only CPT to go by. If there were a national policy, we would follow that, says Gilda Edelstein, practice administrator for Medical Eye Care Associates, a 13-physician practice in Norwood, Mass. As a general rule, you do what the national policy says. Until there is clear guidance from someone regarding how to use 66982, Edelstein is taking the conservative approach: not billing it.

Its true that if CPT had limited the use of 66982 to the examples it provides, the code descriptor would not create such confusion. But keeping the definition broad by using examples instead of limiting scenarios allows for the inclusion of new techniques without rewriting the code.

It is now up to carriers to further define 66982. One carrier, Blue Cross and Blue Shield (BC/BS) of Kansas, did so on April 15. (See box on page 44.) Try to follow the intent of CCI. The BC/BS Kansas policy states that 66982 should not be used to avoid the tenets of the Correct Coding Initiative. It would make sense for CCI to bundle at least what is now bundled in 66984 into 66982.

Billing for ASC Use

HCFA will approve 66982 for ambulatory surgical center (ASC) use. The process is under way. Approval will be retroactive to Jan. 1, 2001. Therefore, if you perform 66982 in an ASC prior to approval, and your claim is denied, keep the denial and refile when HCFA releases the program memorandum.

Another way to bill for ASC use is to code 66982 for the physician, and 66984 for the facility. However, carriers may still reject the claim because the facility and physician codes dont match, and you would have to refile. Code 66982 is in the highest-paying ASC category, as is 66984. The fees are the same: $942. The cost of the IOL is included in the fee.